Doctor Convicted of $6.3M Medicare Fraud Scheme U.S. DoJ Office of Public Affairs - May 10, 2024
A federal jury convicted a Michigan doctor today for causing the submission of over $6.3 million in fraudulent claims to Medicare for medically unnecessary orthotic braces ordered through a telemarketing scheme.
According to court documents and evidence presented at trial, Sophie Toya, M.D., 55, of Bloomfield Hills, signed thousands of prescriptions for orthotic braces for over 2,500 Medicare patients during a six-month period. Toya was not the treating physician for any of these patients and, instead, was connected with some of the patients over the telephone through a telemarketing scheme and spoke to the patients briefly before signing orthotic brace prescriptions for them. For other patients, Toya signed prescriptions without having any contact with them. In one instance, Toya prescribed a lower back brace, right and left shoulder braces, a right wrist brace, right and left knee braces, and right and left ankle braces for a single Medicare patient. Toya also prescribed multiple braces for undercover agents posing as five different Medicare patients after speaking to each agent for less than a minute over the telephone. The evidence presented at trial showed that Toya could not possibly have diagnosed the patients or determined that the braces were medically necessary for them. Nonetheless, Toya signed medical records and prescriptions for braces that falsely represented that the braces were medically necessary and that she diagnosed the beneficiaries, had a plan of care for them, and recommended that they receive certain additional treatment. Toya’s false prescriptions were used by brace supply companies to bill Medicare more than $6.3 million. Toya was paid approximately $120,000 in exchange for signing the fraudulent prescriptions.
The jury convicted Toya of one count of health care fraud and five counts of false statements relating to health care matters. She is scheduled to be sentenced on Aug. 15 and faces a maximum penalty of 10 years in prison for health care fraud and five years in prison on each of the false statements relating to health care matters counts. A federal district court judge will determine any sentence after considering the U.S. Sentencing Guidelines and other statutory factors.
Principal Deputy Assistant Attorney General Nicole M. Argentieri, head of the Justice Department’s Criminal Division; Assistant Director Michael D. Nordwall of the FBI’s Criminal Investigative Division; and Deputy Inspector General for Investigations Christian J. Schrank of the Department of Health and Human Services Office of Inspector General (HHS-OIG) made the announcement.
The FBI and HHS-OIG investigated the case. The case was charged as part of Operation Rubber Stamp, a coordinated nationwide law enforcement operation that targeted medical professionals who participated in fraudulent telemedicine schemes.
Assistant Chief Rebecca Yuan and Trial Attorney Christopher Wenger of the National Rapid Response Strike Force of the Criminal Division’s Fraud Section are prosecuting the case.
The Fraud Section leads the Criminal Division’s efforts to combat health care fraud through the Health Care Fraud Strike Force Program. Since March 2007, this program, currently comprised of nine strike forces operating in 27 federal districts, has charged more than 5,400 defendants who collectively have billed federal health care programs and private insurers more than $27 billion. In addition, the Centers for Medicare & Medicaid Services, working in conjunction with the HHS-OIG, are taking steps to hold providers accountable for their involvement in health care fraud schemes. More information can be found at www.justice.gov/criminal-fraud/health-care-fraud-unit.
If fraud was an agency, it would be federal government's sixth largest
Apr 16, 2024
Comptroller General of the United States Gene Dodaro testified before a U.S. Senate subcommittee on Wednesday, June 14, 2023.
Courtesy of U.S. Senate
(The Center Square) – U.S. taxpayers lose up to $521 billion a year to fraud across the federal government, according to a first-of-its-kind estimate.
The U.S. Government Accountability Office estimated annual fraud costs taxpayers between $233 billion and $521 billion annually, according to a newreportpublished Tuesday. The fraud estimate's range represents 3% to 7% of average federal obligations. The estimate was based on data from fiscal years 2018 through 2022. The government obligated almost $40 trillion from fiscal years 2018 through 2022, but had no reliable estimates of fraud losses.
David Walker, former comptroller general of the United States and a member of the advisory board of Main Street Economics, said the estimate is only part of a larger spending issue.
"The federal government's estimated annual financial losses to fraud of between $233 billion and $521 billion is just the tip of the iceberg," Walker told The Center Square. "When you add waste, abuse, and mismanagement, the numbers are much bigger."
GAO Director of Forensic Audits and Investigative Service Rebecca Shea put the fraud estimate in context. She said that most federal spending isn't fraudulent and that the amount of fraud varies greatly by agency. However, those dollars add up.
"Collectively, the taxpayer is losing a significant amount to fraud every year annually," she said. "And for a little bit of perspective on this relative to agency funding – the top of our range is greater than the budget for all but the top five agencies. And the bottom of our range, it's larger than the ninth largest federal agency. So, the context for that, what we're seeing with this estimate, is that fraud may be the sixth largest agency that we are funding annually, and that's a lot of money that could be going to better use."
There are more ways to put the fraud estimates into context. At the high end of the estimate, $521 billion is enough money for the U.S. Air Force to buy 751 nuclear-capable B-21 Raider stealth bombers at $692 million per plane. The Air Force plans to buy at least 100 such planes. That's also enough money to run the Supplemental Nutrition Assistance Program, formerly known as food stamps, for about 4.7 years at 2023 fiscal year spending levels.
Jared Smith, chief statistician and director of the Center for Statistics and Data Analysis, Applied Research and Methods at GAO, said the estimate wasn't perfect.
"So it's not that we're certain the fraud falls in that range, but we have confidence that this is a number that reflects the severity of the problem," he said.
The GAO used a probabilistic method to estimate a range of outcomes under different assumptions and scenarios where there was uncertainty. The Office of Management and Budget was skeptical of the GAO estimate.
"OMB raised concerns about our estimate and how it would be interpreted," according to the report. "OMB also questioned the plausibility of our estimate."
Brett Rowland is an award-winning journalist who has worked as an editor and reporter in newsrooms in Illinois and Wisconsin. He is an investigative reporter for The Center Square.
