Two indicted for exploiting adult day care patients in Medicare fraud scheme

McALLEN, Texas ‐ A physician and employee have been charged for their roles in a health care fraud scheme involving the submission of more than $3.5 million in claims to Medicare, announced U.S. Attorney Jennifer B. Lowery.

Authorities took Dr. Osama Balhir Nahas, 67, McAllen, and Isabel Moreno Pruneda, 50, Edinburg, into custody today. They are expected to make their initial appearance before U.S. Magistrate Judge Juan F. Alanis Aug. 22 at 9 a.m.

A federal grand jury returned the 15-count indictment Aug. 16. It alleges Nahas is a physician and owner, while Pruneda was an employee at Crosspoint Medical Clinic located in Edinburg. Nahas allegedly paid kickbacks to various adult day care companies to gain Medicare beneficiary information under the guise of providing medical services.

Nahas, Pruneda and other co-conspirators used their access to adult day care facilities to perform a variety of unnecessary medical tests and procedures and order prescriptions for expensive medications that were not needed, according to the charges.

The indictment further alleges many of the patients had their own primary care physicians who were not consulted prior to or after the examinations. Most of the patients were allegedly elderly or disabled and lacked the capacity to consent to the examinations, tests and other procedures that Nahas and Pruneda performed.

In addition, marketers paid Nahas and Pruneda illegal kickbacks in exchange for ordering laboratory tests and prescriptions that were unnecessary and that patients often did not want, according to the charges. In many instances, patients allegedly did not receive their test results or the prescribed medication.

Pruneda also forged patient signatures on consent forms connected to the fraudulent laboratory testing services and prescriptions, according to the charges.

The indictment further alleges more than $3.5 million was billed to Medicare in connection to the fraud scheme. 

Nahas and Pruneda are charged with seven counts of health care fraud and conspiracy to do so, all of which carry a possible 10-year-term of imprisonment, as well as one count of conspiracy to receive illegal remunerations which could result in another five years in prison. Both are also charged with aggravated identity theft which carries a mandatory two years in federal prison which must be served consecutively to any other prison term imposed. All convictions could also result in maximum possible fines of $250,000.

The FBI, Department of Health and Human Services-Office of Inspector General (OIG), Texas Health & Human Services Commission-OIG, Texas Attorney General’s Medicaid Fraud Control Unit and Texas Department of Insurance - Fraud conducted the investigation. Assistant U.S. Attorney Andrew Swartz is prosecuting the case.

An indictment is a formal accusation of criminal conduct, not evidence.
A defendant is presumed innocent unless convicted through due process of law.