(Source: USDOJ) – Dr. Isaac Kojo Anakwah Thompson, 57, of Delray Beach, pled guilty to one count of health care fraud.
Wifredo A. Ferrer, United States Attorney for the Southern District of Florida, Assistant Attorney General William J. Baer, George L. Piro, Special Agent in Charge, Federal Bureau of Investigation (FBI), Miami Field Office, and Shimon R. Richmond, Special Agent in Charge, U.S. Department of Health and Human Services, Office of Inspector General (HHS-OIG), made the announcement.
“The Medicare system relies on our nation’s doctors to diagnose and treat our Medicare beneficiaries,” stated U.S. Attorney Ferrer. “When doctors intentionally misdiagnose their patients for personal gain, they betray the trust of the Medicare system and the patients themselves. This case demonstrates our commitment to the investigation and prosecution of Medicare fraud, in all its varieties and against all groups of offenders.”
“Instead of using the Medicare Advantage program for its intended purpose, Isaac Kojo Anakwah Thompson, a medical doctor, sought to enrich himself by defrauding Medicare of millions of dollars through the submission of false diagnoses for hundreds of patients,” said Michael A. D’Alonzo, Assistant Special Agent in Charge, FBI Miami. “The FBI will not relent in its pursuit of Medicare fraudsters – including greedy doctors.”
“When physicians cheat Medicare by misrepresenting the medical conditions of their patients, our agents will work with our law enforcement partners to hold these individuals accountable for their deceptive schemes,” said Special Agent in Charge Shimon R. Richmond, HHS Office of Inspector General.
According to the court record, including facts admitted during the plea hearing, Dr. Thompson engaged in a scheme to defraud the Medicare Advantage program, a voluntary system which allows Medicare beneficiaries to enroll in health insurance plans sponsored by private insurance companies. For each beneficiary who chooses to enroll in a Medicare Advantage plan, Medicare pays the sponsoring insurance company a fixed, or capitated, monthly fee. Medicare does not adjust the fee based on the cost of providing medical care to the beneficiary. Instead, Medicare adjusts the fee based on the beneficiary’s medical conditions. As a result, Medicare generally pays a larger capitated fee for a beneficiary with more serious medical conditions than it does for a healthier beneficiary. Medicare determines a beneficiary’s medical conditions in part using diagnoses submitted by the beneficiary’s Medicare Advantage plan physician.
Dr. Thompson’s fraudulent conduct involved certain Medicare Advantage plans sponsored by Humana, Inc. These Humana plans operated as health maintenance organizations (HMOs) and each enrolled beneficiary selected a primary care physician (PCP) enrolled in Humana’s network. Before seeing a specialist, the beneficiary generally needed a referral from his or her PCP. Dr. Thompson was an internist who operated a medical clinic in Delray Beach and was a PCP in Humana’s HMO network. As such, a beneficiary enrolled in a Humana HMO Medicare Advantage plan could choose Dr. Thompson as the beneficiary’s PCP. Humana paid Dr. Thompson approximately 80% of the capitated fee for each beneficiary who had selected the defendant as his or her PCP.
Between 2006 and 2010, Dr. Thompson defrauded Medicare by diagnosing 387 Medicare Advantage beneficiaries with ankylosing spondylitis, a rare chronic inflammatory disease of the spine. Dr. Thompson reported these diagnoses to Humana, which in turn reported them to Medicare. As a result, Medicare paid approximately $2.1 million in excess capitation fees, approximately 80% of which went to the defendant. All or almost all of these ankylosing spondylitis diagnoses were false because in fact, the patients did not have the condition. Because the diagnoses were false, the defendant did not have any corresponding increase in his cost to treat the patients.
Sentencing is scheduled for May 18, 2016. At sentencing, the Dr. Thompson faces a maximum possible statutory sentence of 10 years in prison.
Mr. Ferrer and Mr. Baer commended the investigative efforts of the FBI and HHS-OIG. This case is being prosecuted by Assistant U.S. Attorney Marc Osborne and Trial Attorney Paul Gallagher, United States Department of Justice, Antitrust Division.