2012 Award Winners

Investigation of the Year
Investigation of the Year: Honorable Mention
Excellence in Public Awareness
Investigative Excellence Award
Medical Director

Investigation of the Year

United States of America v. Anthony Francis Valdez

Presented To

United States Department of Justice
United States Attorney's Office
Western District of Texas

United States Department of Justice
Federal Bureau of Investigation
El Paso Division

United States Department of the Treasury
Internal Revenue Service
Criminal Investigation

Drug Enforcement Administration
El Paso Division
Tactical Diversion Squad

Texas Office of the Attorney General
Medicaid Fraud Control Unit

United States Postal Inspection Service
Houston Division
San Antonio, Texas Domicile

The Anthony Francis Valdez investigation spanned 9 years and resulted in the conviction of a Texas psychiatrist on 16 counts of health-care fraud related activities; a 25-year prison sentence; forfeiture of seized assets including more than $3 million in cash; residences in El Paso and San Antonio; 5 vehicles; and restitution of over $13 million. Valdez billed over $42 million for peripheral nerve, facet joint injection procedures and Level 4 office visits not performed and received payments of more than $12 million. Valdez also employed unqualified individuals, including the janitor, to administer injections, known as prolotherapy.

Detailed evidence showed that Valdez injured his patients by addicting them to opiates and other prescription medicines. Then Valdez further injured his patients by forcing them - many of whom were elderly or impoverished - to have painful injections in order to receive their pain medicine. Valdez subjected his patients to painful injections which contained "irritants" without being anesthetized. Three patients died while under Valdez's treatment - at least one of an opiate overdose.

The Valdez investigation is an outstanding example of cooperation and collaboration in the fight against health care fraud. Success in the Valdez case by accomplished through the participation of investigators from various state and federal law enforcement agencies as well as the collaboration of these agencies with numerous private health insurance companies, the Texas Department of Health, the Texas Department of Insurance and TRICARE.

The 25 year sentence Valdez received is one of the longest imposed on a White Collar Crime conviction. The severe sentence was the result of extensive efforts to bring to light the heinous actions inflicted by Valdez on his helpless patents.

Congratulations To

AUSA Juanita Fielden
AUSA William F. Lewis, Jr.
United States Department of Justice
United States Attorney's Office
Western District of Texas

Special Agent Roberto Rivera, Jr.
Forensic Accountant Patricia Enriquez, CFE
United States Department of Justice
Federal Bureau of Investigation
El Paso Division

Special Agent Emmanuel Gomez
United States Department of the Treasury
Internal Revenue Service
Criminal Investigation

Diversion Investigator Laura M. Villanueva
Drug Enforcement Administration
El Paso Division
Tactical Diversion Squad

Investigator George J. Jarvis
Investigative Auditor Mirna Ramos
Texas Office of the Attorney General
Medicaid Fraud Control Unit

Postal Inspector Yvette A. Martinez
United States Postal Inspection Service
Houston Division
San Antonio, Texas Domicile

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Investigation of the Year: Honorable Mention

UNITED STATES OF AMERICA v. MAXIM HEALTHCARE SERVICES, INC., et al.

Presented To

United States Department of Justice
United States Attorney's Office
Newark, NJ

United States Department of Justice
Federal Bureau of Investigation
Newark Division - Red Bank Resident Agency

United States Department of Health and Human Services
Office of Inspector General-Office of Investigations
New York Regional Office

United States Department of Veterans Affairs
Office of Inspector General
Criminal Investigations Division
Northeast Field Office

The investigation of Maxim Healthcare Services, Inc. resulted in felony convictions of nine individuals and the largest recovery ever in a home healthcare case. Based on a qui tam alleging that Maxim, a nationwide home health care provider with over 350 offices in 43 states, billed for $20,000 in services not performed at one of its locations, a team of skilled and dedicated investigators developed the allegation into a major fraud investigation against one of the largest providers of home health care in the country. Investigators developed evidence that the firm had defrauded Medicaid programs in more than 40 states out of more than $61 million.

Based on the strength of the evidence amassed by the team, including the guilty pleas of senior executives who admitted to participating in the fraud, Maxim agreed to pay more than $150 million to resolve the case as part of a Global Resolution that included a Deferred Prosecution Agreement filed in the District of New Jersey and a Corporate Integrity Agreement with the Department of Health and Human Services.

The company also underwent dramatic remedial measures as a result of the investigation and prosecution replacing all C-level management, terminating more than 200 employees, enacting a first-rate compliance program, revamping its incentive compensation structure to deter fraud and paying the cost of a Monitor installed pursuant to the Deferred Prosecution Agreement. As a result, the more than 80,000 employees who had no involvement in the fraud can now provide improved service and compliant care to the more than 26,000 chronically ill patients who are provided daily care by Maxim.

Congratulations To

AUSA Jacob T. Elberg
Auditor Barbara Radey, CPA
United States Department of Justice United States Attorney's Office
District of New Jersey

Special Agent Michael Maggipinto
Senior Supervisory Resident Agent Daniel J. McKenna
United States Department of Justice
Federal Bureau of Investigation
Newark Division - Red Bank Resident Agency

Special Agent Eugene Fayer
United States Department of Health and Human Services
Office of Inspector General-Office of Investigations
New York Regional Office

Special Agent Gerard Poto
United States Department of Veterans Affairs
Office of Inspector General
Criminal Investigations Division
Northeast Field Office

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Excellence in Public Awareness Award

Presented To

CNBC's Health Care Hustle
Produced by CNBC Investigations Inc.

CNBC's Health Care Hustle documentary, produced by CNBC Investigations Inc., is recognized for its unprecedented look inside the nationwide epidemic of health care fraud. In cooperation with a joint strike force of the U.S. Health and Human Services Office of Inspector General (HHS-OIG), award winning Senior Correspondent Scott Cohn and the CNBC Investigations Inc. team spent six months on the front lines taking down alleged health fraudsters and criminal rings accused of bilking Medicare and Medicaid out of millions of dollars. Health Care Hustle has helped bring to light the importance of combating fraud in our current health care system.

NHCAA is proud to recognize the CNBC Investigations Inc. team for their outstanding contribution towards the public awareness of health care fraud and its destructive impact on our health care system and our nation's citizens.

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Investigative Excellence Award

Presented To

Humana

In recognition of its unique and innovative Evaluation and Management Outlier Process (EMOP), the Humana Special Investigation Unit is hereby presented with the NHCAA 2012 Investigative Excellence Award. Developed through collaborative efforts by the Clinical and Data Analytics personnel of the Special Investigation Unit, the Evaluation and Management Outlier Process is an extremely effective and efficient health care fraud investigative tool that also incorporates education and peer assistance in its implementation steps.

Congratulations To

Sara Burrall, CPC
Medical Analyst

Joe Miller
Data Analyst

Jean Sexton, Area Director for Humana's Special Investigations Unit accepted the awards on behalf of Sara Burrall and Joe Miller.

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Medical Director Award

Presented To

George M. Koumaras, DDS
Dental Director, Delta Dental of Virginia

The National Health Care Anti-Fraud Association is proud to honor George Koumaras, DDS with the 2012 NHCAA Medical Director Award.

As Dental Director for Delta Dental of Virginia, Dr. Koumaras counts among his many management responsibilities Provider Relations, Professional Review, Clinical Appeals, and Fraud and Abuse Departments. Upon joining Delta Dental in 2006, he led the development of the organization's fraud and abuse program. This undertaking entailed recruiting and training staff, building the program's analytic capacity and fostering relationships with law enforcement. He was also integral to the creation of an innovative analytic tool dubbed MAARS (Metric and Analytic Research System) which provides retrospective analysis of claims data in order to identify outlier behaviors.

Dr. Koumaras has been a champion of forging open communications and building cooperative efforts with local, state and federal agencies that encourage the sharing of information and greater fraud education. Working closely with the Federal Bureau of Investigation, Dr. Koumaras has aided in the investigation and ultimate prosecution of several dental providers for committing fraud.

Special Agent Joseph Parker, Jr. of the FBI shared the following about Dr. Koumaras: "While all insurance carrier's Special Investigations Units are skilled and interested in fighting fraud....I don't know that I have met another SIU director that has pushed the envelope more in developing tools to accomplish his mission. Dr. Koumaras and his staff have been extremely helpful to me by providing me with the tools and knowledge to take his investigative referrals and bring them to a positive judicial outcome. I'm lucky to call him a colleague, a collaborator and friend."

Beyond his own work with Delta Dental of Virginia, Dr. Koumaras has strived to promote involvement of his professional colleagues in the fight against health care fraud. He is a member of the American Dental Association, the American Association of Oral and Maxillofacial Surgeons and served as President of the American Association of Dental Consultants. Dr. Koumaras is an active member of the NHCAA Dental Fraud Interest Group, a frequent speaker at NHCAA conferences, and serves on the NHCAA 2012 Annual Training Conference Committee.

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