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最大健保騙局 Medicare遭詐17億 曝不法商人爛招


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6/20/2019

最大健保騙局 Medicare遭詐17億 曝不法商人爛招

(World Journal) 編譯黃秀媛

美國捲入歷來最大的健保騙局,Medicare被詐財17億元,多州長者遭遇電話轟炸,並被強送支架。(FTC)

85歲的聖地牙哥居民凱爾斯今年3月收到一個大紙箱,一個月後又收到另一箱,裡面裝滿他不需要也沒有訂購的矯正支架;住在東岸的82歲的新澤西州居民愛迪絲,也收到一大箱20個支架,雖然她告訴一再打電話來的推銷員,她不需要這些東西。

他們都向聯邦醫療保險(Medicare)投訴專線通報這種莫名其妙的事情,而聯邦政府今年4月4日在六個州提出連串告訴,指控涉及130家不同醫療用品公司的24人共同用沒有醫療需要的支架,向Medicare詐取17億元。

聯邦督察長處把這個事件稱為「美國歷來最大的健保騙局之一」,指控這些公司利用設在菲律賓和拉丁美洲等各地的電話中心,打電話給成千上萬老年人。




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檢方說,這些醫療用品公司對從未見過的病人做簡單的電子醫療檢驗,然後付錢找醫師開處方,並向Medicare收錢,用以向醫師付回扣。

凱爾斯收到第一個紙箱前,曾接到電話推銷人員不斷轟炸,宣稱他的Medicare福利提供這類醫療用品。他堅持他不想要、也不需要,東西還是送上門。寄第二箱的公司則從未跟他連絡過。

愛迪絲收到的紙箱裝有從腳到肩膀的每一種矯正支架,她把紙箱寄回去,卻仍接到Medicare的報告,表示Medicare為她付了3000元支架費,她還得自付541元。



    
   
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這三家公司都不在已遭起訴之列,而且雖然聯邦展開法律行動,裝醫療支架的紙箱仍在美國各地滿天飛。

維護消費者權益的專家說,老年人收到不要的支架可能很想把東西退回去,然後不理會有關帳單,可是萬一他們日後真的需要用支架,可能被Medicare打回票,因為紀錄顯示他們已獲得這種福利。

此外,一旦Medicare識別號碼在這些業者之前流傳,就可能被買賣,被其他不法業者利用。幸而Medicare最近改變法規,任何老年人如懷疑自己的識別號碼遭竊,都可免費要求新的號碼。






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Department of Justice
Office of Public Affairs

FOR IMMEDIATE RELEASE
Wednesday, June 19, 2019

Louisiana Couple and Their Business Plead Guilty to Operating Sham Medical Reimbursement Account Program that Defrauded the IRS and Program Participants Out of Over $48 Million

A Covington, Louisiana, couple and their company pleaded guilty for their roles in a scheme to create, market and operate a fraudulent medical reimbursement program that defrauded the IRS and program participants out of over $48 million.    

Assistant Attorney General Brian A. Benczkowski of the Justice Department’s Criminal Division, U.S. Attorney Peter G. Strasser of the Eastern District of Louisiana, Special Agent in Charge Thomas J. Holloman of the Internal Revenue Service Criminal Investigation’s (IRS-CI) Atlanta Field Office, Special Agent in Charge Eric J. Rommal of the FBI’s New Orleans Field Office, Special Agent in Charge Steve Grell of the U.S. Department of Labor, Office of Inspector General’s (DOL-OIG) Dallas Regional Office and Regional Director James Purcell of the U.S. Department of Labor, Employee Benefits Security Administration’s Kansas City Regional Office made the announcement. 

Denis Joachim, 53, pleaded guilty to one count of conspiracy to commit money laundering; Donna Joachim, 52, pleaded guilty to one count of conspiracy to defraud the United States; and The Total Financial Group, Inc. (TTFG) pleaded guilty to one count of conspiracy to make false statements and representations in connection with a multiple employer welfare arrangement and five counts of making false statements and representations in connection with a multiple employer welfare arrangement.  All the pleas took place before U.S. District Judge Carl J. Barbier of the Eastern District of Louisiana on May 30, 2019, and were unsealed yesterday.  Sentencings have been scheduled for Sept. 5, 2019, before Judge Barbier.  As part of their guilty pleas, the defendants have agreed to forfeit assets previously seized with a collective value of approximately $6.3 million.  Additionally, the defendants acknowledged a potential loss to the victims totaling more than $48 million and agreed to repay restitution for the amount of loss.



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According to admissions made as part of the guilty pleas, TTFG was a Louisiana business incorporated by Denis Joachim and Donna Joachim with the Louisiana Secretary of State that was most recently located at 406 N. Florida Street in Covington.  TTFG and its owners created and marketed a medical reimbursement account program called “Classic 105,” which operated from about 2012 until January 2017.  Classic 105 claimed to be a multiple employer welfare arrangement that was marketed to employers as a supplemental benefits plan for their employees to reimburse for medical expenses such as co-pays and deductibles; participants in Classic 105 were required to have a primary health insurance plan unrelated to and in addition to Classic 105. 

According to the defendants’ admissions, Classic 105 claimed to be comprised of several components:  a tax-exempt contribution of between $1,000 and $1,600 per month made by an employee (which reduced the employee’s taxable income), a loan from a financial institution back to the employee to make up for the contribution, an insurance policy payable to the lender at the employee’s death to repay the loan and fees paid by the employee and the employer directly to TTFG.  TTFG told prospective employer-clients that participants would never have to make out-of-pocket payments to repay the loan and that as a result of the tax savings, most participants would receive an increase in their net take home pay.  TTFG also told prospective employer-clients that the contributions would be stored in a unique account for each employee-participant and that any money not used by the end of each calendar year would revert to TTFG.  TTFG also charged employee-participants a fee of between $150 and $250 per month and the employer a fee of five percent of each employee’s contribution amount.  At its peak, over 350 employer-clients and 4,400 employee-participants nationwide were enrolled in TTFG’s Classic 105 program. In total, TTFG took in not less than at least $25,543,340.70 in fees from the employer-clients and employee-participants, the defendants admitted.



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According to the defendants’ admissions, TTFG never obtained a single loan or insurance policy for the Classic 105 program, and participants never made any actual contributions.  Rather, TTFG arranged for the contribution, loan and insurance policy to appear as a series of “paper transactions” that, in effect, did nothing more than reduce participants’ taxable wages and employers’ FICA payments improperly, without their knowledge of the impropriety.  Consequently, TTFG and the Joachims admittedly caused the underpayment of at least $23,343,442.70 in federal FICA taxes, as well as the underreporting and underpayment of personal federal income taxes, federal unemployment taxes and state unemployment taxes—amounts for which the employer-clients and employee-participants may be individually responsible.  It also exposed participants to other adverse financial consequences, including fees and penalties on the unpaid tax and ineligibility from certain government programs, including unemployment payments and reduced Social Security payments, the defendants admitted.

In truth, the only money actually paid to TTFG were the fees, which the Joachims used to make numerous personal expenses, including the purchase of a 26-foot boat, a 2016 Grand Design Solitude recreational trailer, a Chevrolet Corvette, a Jeep Wrangler, a Dodge Ram truck, a Mercedes-Benz CL 550 automobile, a GMC Yukon XL Denali, multiple CAN-AM Maverick 1000R off-road vehicles, jet skis, their 13,000 square foot Covington residence, real property located adjacent to their Covington residence, two residences located in Madisonville, Louisiana, 40 acres of property in Bush, Louisiana, and 125 acres of property in Spring City, Tennessee, the defendants admitted.



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This case was investigated by the IRS-CI, the FBI, the DOL-OIG and the Employee Benefits Security Administration.  Assistant U.S. Attorneys Jordan Ginsberg and Maria Carboni of the Eastern District of Louisiana and Trial Attorney Jared Hasten of the Criminal Division’s Fraud Section are prosecuting the case.  Senior Trial Attorney Rebecca Pyne of the Criminal Division’s Organized Crime and Gang Section, Labor-Management Racketeering Unit also provided assistance with the prosecution. 

The Medicare Fraud Strike Force is part of a joint initiative between the Department of Justice and U.S. Health and Human Services (HHS) to focus their efforts to prevent and deter fraud and enforce current anti-fraud laws around the country.  Since its inception in March 2007, the Medicare Fraud Strike Force, which maintains 14 strike forces operating in 23 districts, has charged nearly 4,000 defendants who have collectively billed the Medicare program for more than $14 billion.  In addition, the HHS Centers for Medicare & Medicaid Services, working in conjunction with HHS-OIG, are taking steps to increase accountability and decrease the presence of fraudulent providers.








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