Dr. Isaac Kojo Anakwah Thompson, M.D. 57, of Delray Beach, was sentenced July, 6 2016 by United States District Judge William J. Zloch to 46 months’ imprisonment, to be followed by two years of supervised release, after having previously pled guilty to health care fraud. Dr. Thompson was further ordered to pay restitution in the amount of $2,114,332.33.
Wifredo A. Ferrer, United States Attorney for the Southern District of Florida, Assistant Attorney General William J. Baer, Special Agent in Charge George L. Piro, Federal Bureau of Investigation (FBI), Miami Field Office and Special Agent in Charge Shimon R. Richmond, Department of Health and Human Services, Office of Inspector General (HHS-OIG), Florida region, made the announcement.
According to the court record, including facts admitted during the defendant’s plea hearing and the parties’ statements at sentencing, Dr. Thompson engaged in a scheme to defraud the Medicare Advantage program, a voluntary system which allows Medicare beneficiaries to enroll in health insurance plans sponsored by private insurance companies. For each beneficiary who chooses to enroll in a Medicare Advantage plan, Medicare pays the sponsoring insurance company a fixed, or capitated, monthly fee. Medicare does not adjust the fee based on the cost of providing medical care to the beneficiary. Instead, Medicare adjusts the fee based on the beneficiary’s medical conditions. As a result, Medicare generally pays a larger capitated fee for a beneficiary with more serious medical conditions than it does for a healthier beneficiary. Medicare determines a beneficiary’s medical conditions in part using diagnoses submitted by the beneficiary’s Medicare Advantage plan physician.
Dr. Thompson’s fraudulent conduct involved certain Medicare Advantage plans sponsored by Humana, Inc. These Humana plans operated as health maintenance organizations (HMOs) and each enrolled beneficiary selected a primary care physician (PCP) enrolled in Humana’s network. Before seeing a specialist, the beneficiary generally needed a referral from his or her PCP. Dr. Thompson was an internist who operated a medical clinic in Delray Beach and was a PCP in Humana’s HMO network. As such, a beneficiary enrolled in a Humana HMO Medicare Advantage plan could choose Dr. Thompson as the beneficiary’s PCP. Humana paid Dr. Thompson approximately 80% of the capitated fee for each beneficiary who had selected the defendant as his or her PCP.
Between 2006 and 2010, Dr. Thompson defrauded Medicare by diagnosing 387 Medicare Advantage beneficiaries with ankylosing spondylitis, a rare chronic inflammatory disease of the spine. Dr. Thompson reported these diagnoses to Humana, which in turn reported them to Medicare. As a result, Medicare paid approximately $2.1 million in excess capitation fees, approximately 80% of which went to the defendant. All or almost all of these ankylosing spondylitis diagnoses were false because in fact, the patients did not have the condition. Because the diagnoses were false, the defendant did not have any corresponding increase in his cost to treat the patients.