Health Insurance Fraud Hurts Patients

Watch the full video at and to

In UNITED STATES OF AMERICA v. PATRICK EMEKA IFEDIBA, NGOZI JUSTINA OZULIGBONo. 20-13218, 20-13303, United States Supreme Court, Eleventh Circuit (August 25, 2022) Patrick Ifediba and Ngozi Justina Ozuligbo they pleaded not guilty to charges of corruption in the medical sector and related charges. Ifediba, a doctor, operated a hospital called CCMC and employed Ozu-ligbo, a registered nurse, there.

Convicted of Acting Like a Pill Box & Doubling as a Fraudulent Insurance Scheme

The evidence in the case showed that CCMC prescribed too many opioids to patients who had no medical treatment for them and operated an allergy testing and treatment system that required insured patients to undergo allergy testing and prescribe the drug even after testing. The hospital billed Medicare and private insurance for the tests and treatments.

Ifediba and Ozuligbo were charged with medical fraud, conspiracy to commit medical fraud, illegal theft of hospital funds and conspiracy to commit. Ifediba was charged with illegal distribution of controlled substances without a valid medical purpose and using CCMC as a “pill mill” to distribute controlled substances to patients without medical care.

After a three-week trial with testimony from CCMC patients, medical professionals, and law enforcement officials, the court convicted Ifediba and Ozuligbo on all charges. The court sentenced Ifediba to 360 months in prison and Ozuligbo to 36 months.

MORE

CCMC Is Used As A Pill Mill And Patients Need Insurance For Allergy Tests And Treatment.

Ifediba and his wife, Uchenna Ifediba (“Uchenna”), who was also a doctor, were the only doctors at CCMC. Neither Ifediba nor his wife specialized in painkillers, but they wrote a lot about controlled drugs-opioids. CCMC attracted patients who were willing to wait three hours in a dirty, overcrowded waiting room to receive prescriptions for controlled substances.

In addition to its opioid distribution, CCMC tied insured patients to a fraud scheme. The plot was simple. Every insured patient who came to CCMC had to fill out an allergy questionnaire before seeing a doctor. Regardless of the patient’s response, the allergist tested the patient’s skin for food safety. Regardless of whether the test results were positive or negative, Ifediba ordered immunotherapy to cure tuberculosis and advised experts to order the drug.

Some patients also failed to receive immunotherapy treatments that their insurers paid for.

Insurer Blue Cross Blue Shield of Alabama (“BCBS”) noticed an unusual number of allergic reactions from CCMC and announced that it would investigate the clinic. In preparation for the study, Ifediba asked hospital staff, including Ozuligbo, to change patient records, turn negative allergy results into positive ones and record allergy symptoms in patient questionnaires.

The High Court indicted Ifediba and Uchenna, charging them with multiple counts of illegally distributing controlled substances outside of professional practice and without a legitimate medical purpose. They were also charged with conspiracy to distribute a controlled substance and operating and maintaining CCMC with intent to distribute a controlled substance. All of these cases involved the administration of painkillers. The indictment also charged Ifediba, Uchenna, Ozuligbo, and Ebio with conspiracy to commit medical fraud through a fraudulent scheme and large amounts of medical fraud based on patient records. It also alleged that Ifediba, Uchenna, and Ozuligbo embezzled the proceeds of illegal activities. Uchenna, who suffered a severe stroke, was dismissed from the case as incompetent. Ebio pleaded not guilty to one count of medical fraud and agreed to testify against Ifediba and Ozuligbo.

Jury Hears Evidence of Health Fraud

The state medical expert, Dr. Jim Christensen, told the jury that he was “[a]no” to test patients if they are sick because their health insurance will pay for the test. The Court Judged and Sentenced the Defendants.

The judges handed down the sentences for Ifediba and Ozuligbo. The court ruled that Ozuligbo conspired to commit medical fraud and commit fraud. Ifediba and Ozuligbo were also found guilty of embezzlement and conspiracy.

The court sentenced Ifediba to 360 months in prison and Ozuligbo to 36 months.

ENJOYMENT

Ample Evidence to Support What Ifediba and Ozuligbo Believe.

An appeals court must affirm a conviction unless there is a “reasonable preponderance of the evidence” from which a jury could have found the defendant guilty beyond a reasonable doubt. United States v. Garcia405 F.3d 1260, 1269 (11th Cir. 2005).

Patient Records Sufficient To Support Ifediba’s Health Care Fraud Claim.

The court indicted Ifediba on 10 counts of medical fraud, in violation of 18 USC § 1347(a). In order to be found guilty of a health care fraud charge, the defendant must be shown to have known that the claims made were false.

For all of Ifediba’s problems, patient files and billing records show that either he or his partner, Uchenna, ordered treatment knowing it was unnecessary. Even though the patients did not need the prescriptions, they lied to insurers that the patients needed medical care. Testimony confirmed that Ifediba must have known that the drug was not necessary but paid for the insurance.

The state medical expert, Dr. Jim Christensen, said that it was “inappropriate” to provide medical treatment to a person who has been diagnosed with allergies. Testimony by fraud investigators to insurers confirmed that CCMC submitted allergy-related complaints to these patients. Further evidence showed that Ifediba personally signed off on all Medicare and private insurance bills for unnecessary medical care, thereby defrauding them.

The paper trail and evidence of Ifediba’s fraud is enough for the judges; Anecdotal evidence from patients, although helpful, is not necessary. The court therefore affirmed the jury’s verdict on four counts of health care fraud.

Sufficient Evidence to Support Ozuligbo’s Conviction in the Health Care Fraud Case.

To sustain a conviction for medical fraud in violation of 18 USC §§ 1347 and 1349, the government must establish beyond a reasonable doubt that:

  1. conspiracy existed to commit medical fraud under 18 USC § 1347;
  2. the defendant knew about the conspiracy; and
  3. the defendant knowingly joined.

Because the crime of conspiracy is “predominantly mental,” the government can prove these things through timely evidence and opinion. The government does not have to prove that the defendant knew everything about the conspiracy; it is only necessary to prove “that the defendant knew the essentials of the conspiracy.”

There was overwhelming evidence that CCMC defrauded insurers through a fraudulent allergy scheme. The patients’ medical records showed that Ozu-ligbo was aware of the scheme to offer medical treatment to patients who tested positive for allergies.

Ozuligbo’s conversation with Special Agent Bullock supports the idea that he knew about the plot and participated in it. Bullock arranged to meet with Ozuligbo at his home to interview him. When he stopped on his way, Ozuligbo told Bullock that he had undergone allergy testing and provided medical care at CCMC while working there. He told her that CCMC “only offered exercise and physical therapy to patients with insurance” because “it was expensive and the copays couldn’t afford it.” On the verge of tears, she told him, “I left there to escape the madness and all the crazy patients, and now I work as a peanut farmer.” Id. at 58y.

From this evidence, the jury could have easily found that Ozuligbo was involved in a scheme to provide medical care that was not necessarily needed or provided to patients.

Ifediba’s Decision Was Systematically Correct.

The court heard evidence at trial that CCMC provided controlled substances to people who did not have access to medical care. Evidence also showed that Uchenna wrote its share of “bad drugs,” CCMC dispensed “more drugs” than other hospitals of its size, and that the hospital may have dispensed illegal drugs before and after the crime.

The government did not have to prove that any of the drugs were illegal because the evidence at the clinic showed that the clinic was a mill that did not have a licensed medical practice. A lot of evidence shows that the accused knew that he was illegitimate. The district court affirmed on all counts.

Health insurance fraud, as perpetrated by the defendants, has driven up the cost of health care for honest, sick or injured people and must be stopped. When the fraud is combined with the distribution of illegal drugs to drug addicts and others who had no medical reason for the drug, the doctors are breaking their oath to “do no wrong.” The sentences were, considering the harm to people, insurances and public health plans, they were lenient and when they get out of prison the accused can live a better life for their crimes.

(c) 2022 Barry Zalma & ClaimSchool, Inc.

Barry Zalma, Esq., CFE, now narrows his practice to an insurance consultant specializing in insurance coverage, insurance litigation, insurance bad faith and insurance fraud for both insurers and policyholders alike. . He has practiced law in California for over 44 years as an insurance and claims attorney and over 54 years in the insurance business. He can be reached at zalma@zalma.com.

Subscribe to and receive the subscription-only Excellence in Claims Handling videos at locals.com https://zalmaoninsurance.locals.com/subscribe.

Subscribe to Best Practices in Complaints at

Write to Mr. Zalma at zalma@zalma.com; ; daily news is published on Go to the podcast Zalma Pa Insurance at https://anchor.fm/barry-zalma; Follow Mr. Zalma on Twitter at https://twitter.com/bzalma; Visit Barry Zalma’s videos on Rumble.com at https://rumble.com/c/c-262921; Visit Barry Zalma on YouTube- https://www.youtube.com/channel/UCysiZklEtxZsSF9DfC0Expg; Visit the Insurance Claims Library –