Question.1133 - Complete the findings part of the Fraud examination as required in the template provided in the course.
Answer Below:
FRAUD EXAMINATION REPORT TO:Marie Springer Instructor of PAD 723-IG99 FROM:Estefania Encarnacion Student of PAD 723-IG99 RE:Nurse Practitioner Charged in Alleged $2.3 Million Health Care Fraud Scheme | USAO-RI | Department of Justice DATE:11/25/2023______________________________________________________________________________ Background/Introduction BackgroundThe United States Attorney's Office is overseeing the inquiry District of Rhode Island (USAO-RI), which is being closely monitored by the Department of Justice (DOJ). The charges involve a nurse practitioner who is accused of dealing in criminal actions, primarily submitting false claims to various healthcare programs and insurance companies. This alleged fraudulent behavior is thought to have resulted in significant financial losses within the healthcare system, which has negatively impacted the quality of healthcare services and patient well-being. This incident raises serious issues regarding healthcare professional oversight, the complexities of billing systems, and the more severe issue of healthcare fraud. It emphasizes how critical it is for law enforcement and the judicial system to defend the integrity of the healthcare sector. They also underline the continued necessity for monitoring and restrictions to protect public health and financial resources. IntroductionThe US Attorney's Office in Rhode Island (USAO-RI) is investigating Nurse Practitioner, and the Department of Justice (DOJ) is keeping a careful eye on the case. This event exposes a significant issue in the American healthcare system. This case centers on allegations of fraud against a nurse practitioner who is accused of making dishonest claims to various healthcare programs and insurance companies. This criminal activity's ripple effect extends to the healthcare industry, causing substantial financial damage. These financial setbacks directly affect the quality of healthcare services and the overall welfare of patients. This case serves as a stark reminder of the vulnerabilities present in the healthcare profession, which unethical individuals can manipulate. It also raises concerns about the adequacy of current oversight procedures. We will investigate the complexities of healthcare billing ssystems, explore tactics for detecting and preventing fraudulent claims, and considering the legal ramifications for healthcare personnel participating in fraudulent actions. Additionally, we'll assess the broader impacts on public health and financial stability within the healthcare industry, underscoring the crucial importance of robust monitoring and regulatory measures to uphold the integrity of this essential sector in our society. Executive Summary [For a simple fraud examination, the executive summary should be no more than four or five paragraphs. For a more complex case, the summary may reach a page in length. This section should summarize what actions were performed during the fraud examination, such as reviewing documents, interviewing witnesses, conducting analyses or tests, etc. It provides the reader with an overview of what you did during the examination process. This section should conclude with a summary of the outcome of the examination.] Scope The intended research aims to investigate the intricacies of healthcare fraud within the United States, centering on the recent case of a Nurse Practitioner accused in a purported $2.3 million health care fraud scheme. The proposed research endeavors to delve deeply into the pervasive issue of healthcare fraud within the United States by closely examining a myriad of authentic case studies. Focused on understanding the intricate repercussions, methodologies, and enforcement procedures associated with fraudulent practices, the study aims to navigate the convoluted landscape of healthcare fraud across various industries. The comprehensive exploration will scrutinize the ripple effects of these fraudulent activities on the healthcare system, patients, and the overall economy, while spotlighting the legal, regulatory, and preventive measures. A central emphasis will be placed on analyzing how these fraudulent actions influence the structural integrity of the nation's healthcare system. To achieve this, the research will conduct an exhaustive analysis of multiple real-life healthcare fraud cases, encompassing diverse fraudulent activities present across different sectors of the healthcare industry in the United States. It intends to meticulously investigate the extensive ramifications of these fraudulent occurrences, from billing discrepancies to misleading service claims, shedding light on their diverse impacts on stakeholders, healthcare service quality, patient well-being, and the financial stability of the healthcare sector. Moreover, this research will focus on devising comprehensive strategies, tools, and mechanisms to detect, prevent, and counter healthcare fraud, aiming to fortify the regulatory frameworks and enact reforms conducive to combating fraudulent schemes effectively. The final objective is to recommend policies aimed at enhancing the regulatory landscape and curbing healthcare fraud, thereby contributing essential insights to ongoing discussions on healthcare integrity and setting the groundwork for actionable changes. Approach This is from the ACFE document. This is here to demonstrate what should go here if it were you that was the investigator putting together this report. The government documents you have access to may only supply the names of the agencies involved; include those here. It may say that there was also local law enforcement involved; include that. Generally, it reports that there was one primary investigator; include that. Individuals interviewed can be substituted with those who were charged in the case. Approach for Examining the Alleged Fraudulent Scheme: Team Members: Investigator 1: [Dulce Donovan], DOJ (US Attorney) Investigator 2: [Mary Rogers], DOJ (Assistant US Attorney) Investigator 3: [Richard B. Myrus], DOJ (Acting United States Attorney) Investigator 4: [Zachary A Cunha], USAO-RI Procedures: Data Collection and Review: Obtain and analyze the complaint or indictment filed by the Department of Justice related to the alleged health care fraud scheme. Review financial records, claims, and documents from various healthcare programs, insurance companies, and relevant entities involved. Collect and analyze any public records or reports regarding the accused nurse practitioner's activities and related financial transactions. Interviews and Inquiries: Conduct online-person interviews with pertinent individuals involved, such as insurance company representatives, healthcare program administrators, and witnesses related to the case. Engage in discussions with healthcare professionals, possibly including other nurse practitioners or healthcare personnel familiar with billing systems and fraudulent practices. Legal Investigation: Explore the legal actions or administrative penalties imposed by relevant federal agencies, such as the Department of Justice and the USAO-RI, against the accused nurse practitioner. Examine if the individual has been barred or subject to civil actions by regulatory bodies like the SEC, FINRA, or CFTC. External Document Reviews: Survey credible mainstream media sources like Forbes, Wall Street Journal, and official government websites, including the DOJ, SEC, and other pertinent authorities, to gather additional case-related information. This research approach aims to provide a comprehensive overview and understanding of the alleged fraudulent healthcare scheme, encompassing legal actions, financial transactions, and associated regulatory measures taken by relevant agencies and authorities. Findings (These questions are NOT to be answered yes or no . These questions are here solely to help you understand what information should be included in this section of your paper. This must be written in narrative format. DO NOT include the questions in your paper; if they are in your paper you will lose points). This should be several pages, the bulk of the report. What was the fraud/crime that was suspected? What are the details of the case? How was it carried out? Who did what? What was their position that enabled the fraud? Where was this geographically? Was it civil or criminal or both? What is the relevant time period? (when is it documented to have taken place) Chronology of events as discussed in the documents During the fraud examination, the team involved reviewed the insurance fraud and conducted a court trial with several examinations from 2014 to 2021. Upon examination, Alander E. Istomin, at the age of 55, belonging to Florida, routinely submitted devised health insurance claims for in-person patient service within the served region of East Greenwich, New York, and Florida, while the charges laid involved healthcare fraud, mail fraud, and money laundering charges ("2021 National Health Care Fraud Enforcement Action", 2023).? ? According to the fraud examination by the stakeholders, ALEXANDER ISTOMIN, a registered nurse and director of Rhode Island Diagnostic Center, is also recognized as Advanced Practice Registered Nurse (Nurse Practitioner in adult health), Controlled Substance Registration license Certified Nurse Practitioner (APRN-CNP), and Advanced Practice Registered Nurse (CSR-Aprn). The diagnostic Centers were primarily for billing; the New York office served a similar purpose and was not equipped for patient care. ? In order to have a better understanding of the event, the examiners studied the case from the legal standpoint defining the structure of the program, which includes several of the following definitions - Medicare program is intended to serve individuals over the age of 65 or disabled to provide health care benefit.?The examination shows that ALEXANDER ISTOMIN is one of the certified Medicare providers in New York, Florida. This program is initiated under the United States Department of Health and Human Services (H.H.S.) through widespread C.M.S.'s (Centers for Medicare and Medicaid Services) ("2021 National Health Care Fraud Enforcement Action", 2023; "United States of America Department of Justice," 2021).? ? The examiners highlight that for a provider to be certified, they must be enrolled in C.M.S., and their approval will arrive with a unique provider number, wherein program "Part B" requires beneficiaries to be a part ("Copayment") of the program by contributing 20% while Medicare carries remaining 80% (the 20% is billed by the provider from beneficiaries) ("United States of America Department of Justice," 2021).? ? Nonetheless, the examination also covered how private health insurers since the fraud required assessment of non-governmental like Aetna or Anthem or other programs who are non-governmental program that are run by the premium paid by employers and employees. The examination included a particular administered plan, "A.S.O." (Administrative Services Only), whereby the company funds its own insurance program while outsourcing administrative services and also helping its employees by filing their claims, and the employers pay the private insurer for the claims ("2021 National Health Care Fraud Enforcement Action", 2023).? ? The examination drew in certain A.S.O.'s who are in an arrangement in Aetna, such as Mason Tenders, Dell, and AstraZeneca, wherein Aetna operates as a claim processor to issue employees on behalf of the above-mentioned companies and later gets a reimbursement for the examination iterated that these A.S.O. insurance plans for the employees by private insurers are defined as health care benefit program under Title 18, United States Code, Sec 24(b) ("Nurse practitioner charged in alleged $2.3 million health care fraud scheme," 2021).? In ISTOMIN's case, he was submitting claims to private/commercial insurance carriers that included A.S.O. arrangements with Manson Tenders, Dell, and AstraZeneca.? ? During the examination, the examiners stated that ISTOMIN was a non-participating provider for private non-governmental insurers like Aetna, Anthem, United Healthcare, Cigna, BCBS FL, and BCBS MA; wherein if the provider is not abided by any contract or an agreement that is if there are non-participating they are reimbursed pursuant to the members plan ("United States of America Department of Justice," 2021).? ? According to the fraud assessment, ISTOMIN had knowingly intended a devise scheme and artifice. Claims were made for reimbursement towards commercial health insurers under the Medicare program, submitting a false claim of $2,294,948.83 initially under the violations were under Title 18, United States Code, Section 1347/1341; later after the examination, the final report stated a total fraud amount of $2,309,468.18 ("2021 National Health Care Fraud Enforcement Action", 2023).? ? The charges stem from a scheme spanning from February 2014 to the present, wherein Istomin allegedly submitted fraudulent claims for medical services to commercial health insurers and Medicare.? ? Nature of Fraud: The scheme involved submitting false claims for reimbursement, misrepresenting medical services as medically necessary, and knowingly billing for services that were never provided. Istomin allegedly engaged in billing irregularities, including claiming to provide services in locations where he was not present. Also in 2019, ISTOMIN conducted a transaction through interstate commerce that involved unlawful health care fraud in violation of Title 18, United States Code, Section 1956(a)(1)(A)(i) and 2 ("United States of America Department of Justice," 2021). The examination convicts ISTOMIN for mail fraud offenses under 18 U.S.C. ? 981(a)(1)(C) and 28 U.S.C. ? 2461(c). ? Individuals and Entities Involved: Alexander E. Istomin:?Registered Nurse, Director of RIDC, and associated with New York Medical Center and N.P. in Adult Health Diagnostic and Treatment, PLLC. Rhode Island Diagnostic Center (RIDC):?Location in East Greenwich, Rhode Island. New York Medical Center:?Locations in New York and Fort Lauderdale, Florida. N.P. in Adult Health Diagnostic and Treatment, PLLC:?Locations in New York and Uniondale, New York. Billing Practices: Istomin and RIDC submitted claims to Aetna, United Health Care, Anthem, and BCBSMA using Rhode Island and New York locations. The defendant allegedly billed Medicare and commercial insurers for services provided in different states, sometimes when he was out of the country. ? Specific Allegations: Istomin knowingly waived copayments for Medicare beneficiaries, a practice prohibited by Medicare ("2021 National Health Care Fraud Enforcement Action", 2023). The defendant redirected health care reimbursement checks to his office space in East Greenwich, Rhode Island ("Nurse practitioner charged in alleged $2.3 million health care fraud scheme," 2021). Istomin conducted money laundering by sending a check to J.C.T. Properties, L.L.C., using funds from the fraud ("Nurse practitioner charged in alleged $2.3 million health care fraud scheme," 2021). Chronology of Key Events: February 2014 - Present:?Alleged commencement of the fraudulent scheme. July 9, 2014 - March 10, 2021:?Dates of mail fraud involving checks from Aetna and United Healthcare. February 12, 2019:?Date of money laundering involving a check to J.C.T. Properties, L.L.C. Forfeiture Allegations: The government seeks the forfeiture of $2,294 in U.S. currency, representing gross proceeds traceable to the violations ("United States of America Department of Justice," 2021). Additionally, the government aims to seize any other property of Istomin equal to the value of the forfeitable property. ? Conclusion: The findings suggest a complex fraudulent scheme involving fraudulent billing practices, misrepresentation of services, and money laundering. The government's case is built on a detailed examination of Istomin's activities across multiple states and entities, indicating a deliberate effort to defraud health care benefit programs. Summary [This section should be one or two paragraphs and should succinctly summarize the results of the fraud examination. It should be similar to the outcome stated at the end of the Executive Summary section.] Impact to [Organization Name][The impact section should describe how the fraud impacted the victim organization, including an estimate of the dollar losses or any other type of tangible or intangible damage already suffered or that may occur in the future.]Recommendations [This section is optional; in some instances, it might be preferable to discuss remedial measures or specific recommendations in a separate document. If this section is included, it should state what follow-up action is necessary or recommended, including remedial measures such as a review of internal controls, introduction of a hotline, increased security, etc.] Reference page (In a formal report there is rarely need for references. Those included would generally be legal citations. However, in this report students must include every document used, cited according to the plagiarism and citation guide or the Blue book. Citation managers are not allowed because they make mistakes. Incorrect entries will lose points. This assignment expects to see only federal documents as sources. In cases that include foreign countries, other sources are allowed only on the approval of the instructor. Non-approved sources will lose points. This must be in APA format as indicated in the plagiarism and citation guidelines.) References 2021 National Health Care Fraud Enforcement Action. Criminal Division. (2023, September 26). https://www.justice.gov/criminal/criminal-fraud/2021-nhcf/district-summaries Nurse practitioner charged in alleged $2.3 million health care fraud scheme. District of Rhode Island | Nurse Practitioner Charged in Alleged $2.3 Million Health Care Fraud Scheme | United States Department of Justice. (2021, August 16). https://www.justice.gov/usao-ri/pr/nurse-practitioner-charged-alleged-23-million-health-care-fraud-scheme United States of America Department of Justice (Justice.gov). (2021). United States of America v. Alexander E. Istomin. https://www.justice.gov/media/1178346/dl?inline=More Articles From Research
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