Philip Esformes, the owner of a conglomerate of skilled nursing and assisted living facilities, was found guilty of 20 charges stemming from Medicare fraud. This was the largest criminal healthcare fraud case in the country. His mega empire payed kickbacks and bribes to create a stream of Medicare patients for his businesses. The prosecutors argued Esformes billed over $1billion to Medicare for unnecessary services or services never performed. The matter was bought criminally, and Esformes faces a lifetime prison sentence for his offenses. The jury did not reach a verdict on whether Esformis conspired to commit Medicare fraud.
The Miami Dade Herald article does not indicate how the government learned of the massive fraud. It likely came to the attention through government channels who noticed massive billing trends rather than from a whistleblower. That said, a whistleblower who may have discovered the fraud could have been someone in billing in the nursing homes, or someone "marketing" the facilities (via bribes and kickbacks), or some other inside individual.
Also last week, this criminal matter involving a home health agency resulted in a conviction for the fraudster as well as a judgment to pay over $20 Million in restitution. See the press release here.
These type of cases severely drain the public fisc. Regardless of how the government learns of these cases of Healthcare fraud, we must continue to be watchful of the public money and bring these greedy individuals and companies to justice.