Florida man arrested in multimillion-dollar Medicare equipment billing scheme

SWISS is the third defendant charged, following the arrests in December of co-defendants ERIN FOLEY and TED ALBIN. As alleged in a four-count Indictment unsealed today, SWISS ran two medical supply companies that illegally submitted more than $17 million in claims to Medicare, submitting those claims through a Medicare billing company run by FOLEY and ALBIN. FOLEY and ALBIN are charged with using that billing company to bill Medicare for more than $25 million in fraudulent claims for durable medical equipment ("DME"), on which Medicare and related private insurers paid out more than $9 million.

SWISS was presented this morning before U.S. Magistrate Judge William Matthewman in West Palm Beach, Florida, and ordered to appear again in the West Palm Beach federal courthouse on February 5 for a removal hearing. In Manhattan, the case is assigned to U.S. District Judge John G. Koeltl.

U.S. Attorney Damian Williams said: "As alleged, the defendants devised a scheme to get rich quick by fraudulently billing Medicare, a taxpayer-funded service, for medical equipment. Their alleged scheme bilked taxpayers of millions of dollars, and fraudulent practices such as this can drive up the cost of health care for everyone. Close watch for fraud must be paid to our taxpayer-funded programs to ensure fairness for all Americans who rely on these critical systems for medical care."

According to statements made in court and publicly filed documents in this case:[/1]

From approximately 2016 through April 2019, SWISS operated Tropical Medical Marketing, Inc., a call center which cold-called Medicare beneficiaries and used their personal and medical information without the beneficiaries' knowledge or consent to prepare orders for DME. SWISS then sold these DME orders to co-conspirators who illegally obtained purported signatures or "authorizations" of health care providers so that fraudulent claims could be submitted to Medicare for reimbursement.

From approximately 2017 through April 2019, SWISS also operated two DME supply companies: Modern Medical Equipment, Inc., which SWISS used primarily to bill Medicare directly under Medicare Part B, and A&E Medical, Inc., which SWISS used primarily to bill private insurance companies under Medicare Part C, also known as "Medicare Advantage."

To obtain the DME orders that SWISS used to support his unlawful claims to Medicare, SWISS used two unlawful methods: (i) purchasing such orders outright, and (ii) using patient information that SWISS had generated through his call center and purchasing the purported signatures or authorizations of health care providers. SWISS caused the two DME supply companies that he controlled to submit claims to Medicare for more than $17 million -- through the billing company operated by FOLEY and SWISS -- on which Medicare paid out nearly $5 million.

FOLEY and ALBIN owned and controlled Grapevine Professional Services, Inc. ("Grapevine"), a billing company that they used to bill Medicare for more than $25 million, and to collect more than $9 million, through claims based on orders for DME that had been unlawfully sold and bought. Most of these unlawful purchases of DME orders were by Grapevine customers that were registered with Medicare as DME supply companies. Additional unlawful purchases were made directly by FOLEY and ALBIN through three DME supply companies that they themselves owned and controlled. Once these DME orders were unlawfully purchased, FOLEY and ALBIN used those orders as the basis for fraudulent claims to Medicare and to private insurers covered by Medicare Part C. Approximately 70% of the fraudulent billing submitted by Grapevine came from the two DME supply companies controlled by SWISS.

In addition, FOLEY and ALBIN acted as brokers of DME orders, introducing Grapevine customers who wished illegally to buy DME orders to co-conspirators who illegally sold them orders. In return for such introductions of buyers to sellers, FOLEY and ALBIN received additional kickbacks, both in the form of cash and in the form of additional DME orders. FOLEY and ALBIN also profited through these introductions by gaining additional illegal billing business for Grapevine. Following these introductions, FOLEY and ALBIN continued to oversee the relations between buyers and sellers of DME orders, for example by tracking how many orders particular sellers owed to particular buyers.

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SWISS, 51, of West Palm Beach County, Florida, is charged with conspiracy to commit health care fraud and wire fraud, which carries a maximum sentence of 20 years in prison; health care fraud, which carries a maximum sentence of 10 years in prison; wire fraud, which carries a maximum sentence of 20 years in prison; and conspiracy to violate the Anti-Kickback Statute, which carries a maximum sentence of five years in prison.

The maximum potential penalties are prescribed by Congress and are provided here for informational purposes only, as any sentencing of the defendants will be determined by the judge.

Mr. Williams praised the outstanding investigative work of the U.S. Department of Health and Human Services, Office of the Inspector General.

This case is being handled by the Office's Complex Frauds and Cybercrime Unit. Assistant U.S. Attorneys David Raymond Lewis and Rushmi Bhaskaran are in charge of the prosecution.

The charges contained in the Indictment are merely allegations, and the defendants are presumed innocent unless and until proven guilty.

[1/] The Indictment and the description of the Indictment set forth herein constitute only allegations, and every fact described should be treated as an allegation.

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Original text here: https://www.justice.gov/usao-sdny/pr/florida-man-arrested-role-multimillion-dollar-medicare-scheme-based-fraudulent-billing