Raymond and Emelitza Arias are going to prison for billing for treatment of HIV patients that never happened.
 
Having pleaded out to fraud charges last October, the Ariases were sentenced last week. On May 7, Raymond Arias, 42, got 100 months; on May 8, his wife Emelitza, 25, got one year. The husband was also ordered to pay $5.4 million in restitution, and the wife to pay $531,883. The Ariases also agreed to forfeit $40,000 seized by authorities during the investigation of their case.
 
Raymond Arias ran Elite Wellness, a clinic in Westland, Mich. that “purported to specialize in treating patients with Human Immunodeficiency Virus (H.I.V.) by claiming to provide infusion therapy,” per the federal indictment. His wife Emelitza was in charge of Carefirst Occupational and Rehabilitation Clinic in Detroit.
 
The original government complaint sworn out by FBI Special Agent Peter A. Hayes against Emelitza Arias shows that the Department of Justice’s Program Safeguard Contractor (PSC), Trust Solutions, showed “a 99.5% denial rate of 40 reviewed medical claims submitted by Elite,” which led to the investigation of Carefirst.
 
“Elite and Carefirst have employees in common,” the complaint stated, “and have billed Medicare for similar anomalous treatments for the same Medicare patients.”
 
Though Carefirst was supposed to be a PT and OT clinic, most of its Medicare claims were for J-code J2353 (Injection, octreotide, depot form for intramuscular injection, 1 mg). Octreotide, aka Sandostatin, is sometimes used to treat diarrhea in HIV patients.
 
Investigators discovered that patients denied receiving the treatment for which the Ariases billed, and that the distributors of Sandostatin in the area had never delivered the drug to either Elite or Carefirst.
 
Also, in investigating of Carefirst’s finances, Hayes found that “numerous purchases were noted within the bank statements, which appear to be of a personal nature,” per the complaint. “This type of activity in a business account is often an indicator of an account with no legitimate business purpose, and an effort to hide one’s personal purchases through a business, or a means to pay employees or co-conspirators by giving them means to make purchases through a ‘business account.’”
 
That’s just one of the red flags Medicare investigators look for. You can learn about others by reading Part B News compliance stories.