Greater Miami Behavioral Healthcare: Patient Referrals on the Marketing Bill

The Greater Miami Behavioral Healthcare fraud scheme involved purchased patient referrals and false records at a provider that billed Medicare approximately $63 million from 2006 through 2014. In the criminal case against its consultant and Medicare biller, the Justice Department’s guilty-plea account describes her admissions to authorizing kickbacks for beneficiaries and helping conceal the payments. Someone inside this operation could see a marketing expense, a patient admission or a claim. The case connected all three.

The provider’s full name was Greater Miami Behavioral Healthcare Center Inc. It operated a partial hospitalization program in Miami, purporting to provide intensive treatment for people with severe mental illness. Health Care Solutions Network was a separate operator with its own PHP fraud case. The Greater Miami account centers on a different payment intermediary: HNB-Stell Care Inc.

How Does Patient Brokering Work?

Patient brokering turns access to patients into something a treatment business buys. In Greater Miami’s case, the consultant admitted that she directed and authorized kickbacks and bribes to patient brokers and others in exchange for Medicare beneficiary referrals. The payment bought the referral that brought the beneficiary into the PHP operation.

According to her guilty plea, brokers solicited beneficiaries from assisted living facilities, halfway houses and drug courts throughout the Southern District of Florida. Brokers owned shell companies that received concealed kickback payments.

A referral source can appear in a patient’s intake information while a different company appears on the payment. We would want to understand the relationship between the person sending patients and the business receiving money. A staff member who knows that relationship can explain a transaction that looks like an ordinary vendor expense on its face.

What the PHP Claim Was Supposed to Represent

A partial hospitalization claim represents intensive mental health treatment. Greater Miami’s biller admitted that personnel routinely falsified medical records for recruited beneficiaries to support false Medicare claims. Recruitment supplied the patients. Falsification supplied the apparent clinical support for billing.

The PHP payment structure explains why that connection matters. In CMS’s billing framework, the facility payment is for a program day, supported by the component services, dates, units and charges reported for it. The work represented by the day’s claim therefore matters alongside the fact that a beneficiary entered a program.

For staff reviewing PHP billing today, CMS’s coverage description helps explain what falsified records can hide: whether patients can participate in intensive treatment, whether they need it in place of inpatient care and how a physician-reviewed treatment plan addresses that need. In Greater Miami’s case, the biller’s admission connected false records directly to claims sent to Medicare.

We see a particularly ugly bargain here: a program presented as intensive treatment for severely ill people used purchased referrals and false records to support its billing. Patients became the route to the money.

The Biller Who Also Authorized the Kickbacks

The consultant’s role crossed the boundary between billing and patient acquisition. She admitted both serving as Greater Miami’s Medicare biller and directing referral payments. She also admitted receiving a percentage of the PHP’s Medicare reimbursement as compensation. Her financial interest followed the reimbursement coming into the business.

That combination gives an insider something more useful than a job title. The person processing claims also exercised authority over payments for referrals and shared in the resulting reimbursement. When we examine a similar account, we want to understand those responsibilities together: who could authorize the expense, who knew its purpose and how that person was compensated.

The FBI and the Department of Health and Human Services Office of Inspector General investigated the consultant’s case.

HNB-Stell Put a Business Label on Referral Payments

HNB-Stell Care was the sham staffing company through which monthly kickbacks were disguised as outreach or marketing payments, according to the consultant’s plea. She admitted working with two other defendants to conceal payments to the brokers’ shell companies. The staffing-company name and the marketing description gave the referral payments the appearance of business expenses.

The people buying referrals also controlled how the payments were described. We look past the expense label to the relationship it records: what the recipient supplied, who approved the payment and which beneficiaries the arrangement brought into the program.

Calling it marketing did useful work for the scheme. It made buying patients sound like promoting a service.

What Evidence Is Needed to Prove Fraud?

For a PHP referral-payment case, the useful evidence connects the beneficiary’s arrival, the payment for that referral, the treatment record and the Medicare claim. The Greater Miami consultant’s plea account makes those connections unusually concrete: the consultant authorized payments, helped conceal them, knew of routine record falsification and received a share of reimbursement.

Referral and payment records, clinical and billing records, and management and compensation records give us different ways into that account. Intake information can connect a patient to a referral source. Vendor invoices and payment instructions can identify who received money and who approved it. Treatment documentation and claims show what the program represented to Medicare, while an insider can explain the care actually delivered. We bring that knowledge together to assess a health care fraud case.

You may know the payment arrangement without knowing how the claims were prepared, or know the treatment records without seeing the vendor accounts. We work with the part you understand and connect it to the decisions behind the billing.

A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers.

You Know What the Marketing Payment Bought

If you know how a PHP’s referrals, vendor payments and billing fit together, speak to one of our whistleblower experts about what the marketing payments really bought. We build the case with you and bring in behavioral health fraud whistleblower lawyers who understand purchased referrals and false treatment records. We stay beside you as partners throughout the case.