A former fraud investigator for Anthem is among five people in California facing federal healthcare fraud charges in connection to two San Fernando Valley clinics and an alleged scheme that defrauded health insurance companies of million of dollars, the Department of Justice announced.
An unsealed federal grand jury indictment alleges that five defendants – including a former fraud investigator at Anthem Blue Cross and a physician were part of a years–long healthcare fraud conspiracy against at least eight health insurance companies, the DOJ said.
Roshanak Khadem, owner and operator of R&R Med Spa and its successor company, Nu-Me Aesthetic and Anti-Aging Center, physician Roberto Mariano, who helped operate the clinics, and Gary Jizmejian, a former senior investigator at the Anthem's Special Investigations Unit were among those arrested and charged.
According to the DOJ who cited the indictment, Khadem and others obtained insurance information from patients and billed insurance companies for services that either weren't needed or were never performed. The fraudulent proceeds were then used as "credits" by patients for free or discounted cosmetic procedures including facials, laser hair removal and Botox injections.
The allegations also state that in return for cash payments, Jizmejian allegedly contributed to the scheme by providing confidential Anthem information that helped them submit fraudulent bills. In September 2012, Jizmejian provided insurance billing codes that could be used to submit fraudulent claims without detection, such as the code for an allergy-related lab test, which he allegedly told Khadem to use to submit a "large numbers of bills" to Anthem, the DOJ said.
Jizmejian also allegedly helped conceal the scheme from insurance companies by helping Khadem to "avoid responding to inquiries from fraud investigators, diverting attention of other Anthem SIU investigators away from the clinics, and closing Anthem investigations into fraud that were being committed at the clinics," the DOJ said.
At least $20 million in claims was billed to the insurance companies, and roughly $8 million was paid out, the DOJ said citing the indictment. The International Longshore and Warehouse Union, Pacific Maritime Association Benefit Plan, which is the health benefit plan that covers longshore workers in Southern California and their dependents, were defrauded as a result of the scheme, according to the indictment, as well as the Federal Employees Health Benefits Program, which provides health insurance for federal employees.
The defendants were charged with one count of conspiracy to commit healthcare fraud and 13 counts of healthcare fraud. The indictment also contains criminal forfeiture allegations that seek forfeiture of the the illegal proceeds from the alleged scheme. Each count charged in the indictment carries a statutory maximum sentence of 10 years in prison.
This is the first case so far this year that involved an former fraud investigator as one of the accused offenders, though it is certainly not the first one involving a physician or leader. Numerous physicians are getting wrapped up in illegal activity, particularly in kickback or reimbursement schemes as well as pill mill operations. At least three cases so far this year have involved alleged or convicted wrongdoing on the part of hospital or health system leadership.
Twitter: @BethJSanborn
Email the writer: beth.sanborn@himssmedia.com