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convince the patient to schedule an appointment. Sometimes the patient Employee
1 was attempting to contact was dead. In an October 5, 2018, letter of resignation
that Employee 1 left for AUSTIN, Employee 1 stated she “can no longer abide by
putting my morals to the side for the company’s benefit” and “I believe I will be
better suited for a company that is more honorable in [its] day to day activities.”

36. In2018, DEGRAFT-JOHNSON began calling nursing home directors
and informed them that there were rumors circulating that he was falsely billing for
some of the nursing homes’ patients. DEGRAFT-JOHNSON told the nursing home
directors that these rumors were false and spread by persons at Hospital B who could
not stand to see him succeed.

37. DEGRAFT-JOHNSON also obtained patients for HVINF through a
relationship with Organization C, which provides citizens of Gadsden County,
Florida, with diabetes education and care. Organization C partners with area
churches to perform an outreach to those who need assistance. Organization C paid
DEGRAFT-JOHNSON $1,600 per month. DEGRAFT-JOHNSON participated
in the twice monthly diabetes classes held throughout Gadsden County.
Organization C also had surveys printed and handed them out to attendees to
complete. These surveys asked the residents about their health conditions and

circulatory issues. Organization C gave these surveys to DEGRAFT-JOHNSON.

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service. DEGRAFT-JOHNSON added SUR appointments for the November | and
November 13 dates of service. AUSTIN modified the SUR appointments to show a
Visit Status of “Checked Out.” Medicare paid DEGRAFT-JOHNSON $35,426.64
in reimbursements for these claims.
59. On January 9, 2019, DEGRAFT-JOHNSON traveled to London,
United Kingdom. He returned to the United States on January 21, 2019.
a. The patient M.B. is a 63 year old female and CHP beneficiary.
MLB. had an established patient visit with a medical assistant at HVINF on January
14, 2019, while DEGRAFT-JOHNSON was abroad. On January 24, 2019,
DEGRAFT-JOHNSON added a SUR appointment to the January 14, 2019, EMR
calendar for M.B. and electronically signed an operative report falsely stating that
he had performed an atherectomy on M.B. on January 14, 2019. AUSTIN then
modified the SUR appointment to show a Visit Status of “Checked Out.”
DEGRAFT-JOHNSON caused Company A to bill CHP $21,478.00 for this
procedure under CPT Code 37229 and $2,944 for CPT code 37233. CHP paid
HVINF $16,524.39 for that claim. CHP paid DEGRAFT-JOHNSON $29,679.96
for two other atherectomy claims on dates of service January 7 and February 6, 2019.
Images available for the January 7 date of service show M.B.’s condition as normal.
b. The patient C.B. is a 53 year old male and BCBS beneficiary.

C.B. also had an established patient visit with a medical assistant at HVINF on

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$9,361.07 for this fraudulent claim. Medicare paid DEGRAFT-JOHNSON a total
of $52,022.06 in reimbursement for a total of six atherectomies which DEGRAFT-
JOHNSON claimed he performed on L.S.W.

b. The patient E.H. is a 65 year old male and BCBS beneficiary.
E.H. was scheduled for an established patient visit on October 26, 2018. On
November 7, 2018, DEGRAFT-JOHNSON added a SUR appointment to the
October 26 EMR calendar for EH. DEGRAFT-JOHNSON also created and
electronically signed an operative report falsely stating that he performed an
atherectomy on E.H. on October 26, 2018. That same day, Company A billed
Medicare $21,478.00 under CPT code 37229, and $2,944.00 under CPT code 37233,
for this claim. On November 12, 2018, AUSTIN modified the SUR appointment to
show a “Visit Status” of “Checked Out.” BCBS paid DEGRAFT-JOHNSON
$14,827.96 for this fraudulent claim. BCBS paid DEGRAFT-JOHNSON a total of
$55,779.98 for the six atherectomies which DEGRAFT-JOHNSON claimed to
have performed on E.H.

c. The patient F.S. is a 75 year old male and Medicare beneficiary.
F.S. was scheduled for an established patient visit on October 30, 2018. On
November 1, 2018, DEGRAFT-JOHNSON added a SUR appointment to the EMR
calendar for F.S. DEGRAFT-JOHNSON also created and electronically signed an

operative report falsely stating that he performed an atherectomy on F.S. on October

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61. The patient J.G. is a 51 year old female and BCBS beneficiary.

a. According to J.G., she has a genetic blood disorder which affects
her organs. Because of this, in 2018, J.G. sought to establish a relationship with a
cardiologist. Her friend, S.R., was a patient of DEGRAFT-JOHNSON and
suggested that J.G. see him. J.G. discussed it with her primary care physician and
decided to establish with DEGRAFT-JOHNSON in December 2018. J.G. told
DEGRAFT-JOHNSON that she had some swelling in her ankles and he had an
ultrasound performed on her legs. DEGRAFT-JOHNSON told her that she may
have some blockages in the arteries of her legs and that she needed an angiogram.
DEGRAFT-JOHNSON performed two angiograms on J.G. about two weeks apart
in February and March 2019. DEGRAFT-JOHNSON told J.G. that he did not find
any blockages and that she needed to have a venous ablation performed.
DEGRAFT-JOHNSON’s ultrasound tech performed the ablation during a different
office visit. The procedure was very painful and J.G. decided not to return to
DEGRAFT-JOHNSON for any more procedures.

b. A review of EMR and BCBS records for J.G. shows that
DEGRAFT-JOHNSON electronically signed operative reports falsely stating that
he had performed four atherectomies on J.G. and caused corresponding fraudulent

claims to BCBS, as follows:

DATE OF CLAIM CPT HCBP AMOUNT
SERVICE DATE CODE(S) | PROGRAM | CLAIMED

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© '@:0 0:0 0 '0 ©@:4

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23. AUSTIN knew that DEGRAFT-JOHNSON was creating phantom
surgeries from the inception of the scheme. AUSTIN usually modified the SUR
appointment after DEGRAFT-JOHNSON completed and signed the false
operative report to indicate that the patient was “Checked Out.”

24. After DEGRAFT-JOHNSON wrote and electronically signed
operative reports claiming he performed an atherectomy, the report went into a
portion of the EMR for billing purposes. Employee 3 was an account manager at
Company A. HVINF was Employee 3’s main client. Employee 3 coded surgical
claims for HVINF. Employee 3 coded atherectomy claims under CPT codes 37225,
327227, 37229 (and the add-on code 37233) based on DEGRAFT-JOHNSON’s
statements in his operative reports that he performed an atherectomy and the
particular artery involved. Employee 3 prepared and submitted the atherectomy
claims based on HVINF’s reimbursement schedule. Claims under CPT Code 37225

were billed in the amount of $21,752.00. Claims under the CPT Code 37229 were

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70. Atherectomy comes in different forms, including rotational, orbital,
directional, and laser. In his operative reports, DEGRAFT-JOHNSON described
consistent use of either the Medtronic Turbohawk, the Boston Scientific Jet Stream
rotational atherectomy system, or the Boston Scientific Rotoblator rotational
atherectomy system. Purchase records also indicate that DEGRAFT-JOHNSON
utilized the Medtronic Silverhawk, and Hawk One atherectomy systems. From
approximately in or around September 2015 to in or around October 2016,
DEGRAFT-JOHNSON primarily used the Medtronic Turbohawk system to
perform atherectomies. From in or around October 2016 until February 13, 2020,
DEGRAFT-JOHNSON primarily used the Boston Scientific Jet Stream and the
Boston Scientific Rotoblator atherectomy systems.

71. To properly utilize these systems to perform atherectomies, certain non-
reusable components are necessary. The necessary, non-reusable equipment costs,
with some variation, roughly two thousand dollars per procedure. DEGRAFT-
JOHNSON did not purchase sufficient equipment to perform as many atherectomies
as he claimed to have performed because medical device representatives, who were
usually present during the procedures, might have noticed the phantom claims (Steps
2 and 4) and in order to maximize the profit of the conspiracy and scheme to defraud

health care benefit programs.

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falsely stating that he had performed an atherectomy on J.M. on June 21, 2019.
AUSTIN then modified the SUR appointment to show a Visit Status of “Checked
Out.” DEGRAFT-JOHNSON caused Company A to bill BCBS $21,478.00 for this
procedure under CPT Code 37229 and $2,944.00 under CPT Code 37233. BCBS
paid HVINF $15,339.27 for that claim. BCBS paid DEGRAFT-JOHNSON a total
of $40,446.89 for three other atherectomy claims related to J.M.

68. DEGRAFT-JOHNSON traveled to Shanghai, China, on October 16,
2019. He returned to the United States on October 21, 2019. The patient T.T. is an
80 year old female and Medicare beneficiary. On October 17, 2019, T.T. had an
established patient visit with a medical assistant at HVINF while DEGRAFT-
JOHNSON was abroad. On October 23, 2019, DEGRAFT-JOHNSON added a
SUR appointment to the October 17, 2019, EMR calendar for T.T. and electronically
signed an operative report falsely stating that he had performed an atherectomy on
T.T. on October 17, 2019. AUSTIN then modified the SUR appointment to show a
Visit Status of “Checked Out.” DEGRAFT-JOHNSON caused Company A to bill
BCBS $21,478.00 for this procedure under CPT Code 37229. Medicare paid HVINF
$9,358.87 for that claim. Medicare paid DEGRAFT-JOHNSON a total of
$28,052.29 for three other atherectomy claims related to T.T.

69. DEGRAFT-JOHNSON traveled to the United Kingdom on December

12, 2019. He returned to the United States (New York) on December 18, 2019.

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Respectfully submitted,

LAWRENCE KEEFE

Ate
2-——.

MARK O’MA: AND. J. GROGAN
Attorney for Defendant Assistant United States Attorney
Northern District of Florida
Florida Bar No. 85932
Date: 111 North Adams Street, Fourth Floor
Tallahassee, Florida 32301
(850) 942-8430
andrew.grogan@usdoj.gov

Date: 12/19/ aS »

Date: |2/ |6/ ‘wo

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for A.H. and electronically signed an operative report falsely stating that he had
performed an atherectomy on A.H. on April 25, 2019. AUSTIN then modified the
SUR appointment to show a Visit Status of “Checked Out.” DEGRAFT-
JOHNSON caused Company A to bill Medicare $21,478.00 for this procedure
under CPT Code 37229 and $2,944.00 for CPT code 37233. Medicare paid HVINF
$10,404.77 for that claim. Medicare paid DEGRAFT-JOHNSON a total of
$39,502.96 for three other atherectomy claims related to A.H. Images available from
the April 2 and April 16, 2019, dates of service show A.H.’s condition as normal.
65. DEGRAFT-JOHNSON traveled to Shanghai, China, on May 8, 2019.
He returned to the United States on May 13, 2019. The patient R.L. is a 83 year old
female and CHP beneficiary. R.L. had an established patient visit with a medical
assistant at HVINF on May 9, 2019, while DEGRAFT-JOHNSON was abroad. On
May 15, 2019, DEGRAFT-JOHNSON added a SUR appointment to the May 9,
2019, EMR calendar for R.L. and electronically signed an operative report falsely
stating that he had performed an atherectomy on R.L. on May 9, 2019. AUSTIN
then modified the SUR appointment to show a Visit Status of “Checked Out.”
DEGRAFT-JOHNSON caused Company A to bill CHP $21,478.00 for this
procedure under CPT Code 37229. CHP paid HVINF $11,679.11 for that claim.
CHP paid DEGRAFT-JOHNSON a total of $39,502.96 for three other atherectomy

claims related to R.L.

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subsequently scheduled for four diagnostic angiographies whether medically
necessary or not.
45. The patient N.S. is a 78 year old female and a WellCare beneficiary.

a. According to the patient, N.S. went to HVINF for pain in her
legs. DEGRAFT-JOHNSON performed four angiograms on N.S. DEGRAFT-
JOHNSON told her she had no blockages in her arteries. The procedures performed
by DEGRAFT-JOHNSON did not alleviate the pain in N.S.’ legs. Another
physician later diagnosed N.S. as suffering from arthritis.

b. A review of EMR records for N.S. shows that DEGRAFT-
JOHNSON electronically signed operative reports falsely stating that he had
performed ten atherectomies on N.S., and caused the submission of corresponding

fraudulent atherectomy claims as follows:

DATE OF CLAIM CPT HCBP AMOUNT
SERVICE DATE CODE(S) | PROGRAM | CLAIMED
06/08/2016 | 06/09/2016 37229 WellCare | $21,478.00
07/05/2016 | 07/13/2016 37229 WellCare | $21,478.00

02/21/2017 _| 02/22/2017 37225 WellCare | $21,752.00
02/23/2017 | 02/28/2017 37229 WellCare | $21,478.00
06/20/2017 _| 06/26/2017 37225 WellCare __| $21,752.00
06/22/2017 | 06/28/2017 37229 WellCare | $21,478.00
37233 $2,944.00
11/19/2018 11/20/2018 37225 WellCare | $21,752.00
11/29/2018 12/06/2018 37229 WellCare | $21,478.00

37233 $2,944.00
12/10/2018 12/21/2018 37225 WellCare $21,752.00
12/12/2018 12/22/2018 37229 WellCare $21,478.00
37233 $2,944.00

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January 14, 2019, while DEGRAFT-JOHNSON was abroad. On January 24, 2019,
DEGRAFT-JOHNSON added a SUR appointment to the January 14, 2019, EMR
calendar for C.B. and electronically signed an operative report falsely stating that he
had performed an atherectomy on C.B. on January 14, 2019. AUSTIN then modified
the SUR appointment to show a Visit Status of “Checked Out.” DEGRAFT-
JOHNSON caused Company A to bill BCBS $21,478.00 for this procedure under
CPT Code 37229 and $2,944 for CPT code 37233. BCBS paid HVINF $14,822.96
for that claim. BCBS paid DEGRAFT-JOHNSON a total of $55,789.98 for four
atherectomy claims related to C.B. Images available for three other dates of service
show C.B.’s condition as normal.

c. The patient H.R. is an 89 year old male and CHP beneficiary.
H.R. had an established patient visit with a medical assistant at HVINF on January
15, 2019, while DEGRAFT-JOHNSON was abroad. On January 24, 2019,
DEGRAFT-JOHNSON added a SUR appointment to the January 15, 2019, EMR
calendar for H.R. and electronically signed an operative report falsely stating that he
had performed an atherectomy on H.R. on January 15, 2019. AUSTIN then modified
the SUR appointment to show a Visit Status of “Checked Out.” DEGRAFT-
JOHNSON caused Company A to bill CHP $21,478.00 for this procedure under

CPT Code 37229 and $2,944 for CPT code 37233. CHP paid HVINF $14,252.69 for

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9. Blue Cross Blue Shield (“BCBS”), Capital Health Plan (CHP), United
Healthcare (“UHC”), WellCare, Humana, Florida True Health, Wisconsin
Physician’s Service, Aetna, Cigna, AARP, Bankers Life, Care Improvement Plus,
CHA, CHAMPVA, Magellan Complete Care, and Meritain Health were private
health insurers doing business in the Northern District of Florida, and each was a
“health care benefit program” as defined by Title 18, United States Code, Section
24(b), which affected commerce.

10. The American Medical Association assigns and publishes numeric
codes, known as the Current Procedural Terminology (CPT) codes. Health care
benefit programs use these codes to understand and evaluate claims submitted by
providers and to decide whether to issue or deny payment. “Upcoding” is the illegal
practice of billing at a higher CPT code than the service which was actually
performed

11. Together Defendants conspired to implement a scheme to submit
claims for reimbursement to, and obtain money from, health care benefit programs
for interventional vascular procedures which were never performed.

12. DEGRAFT-JOHNSON often performed on HVINF patients a
procedure known as a diagnostic angiography. It is an invasive procedure for the
purpose of evaluating the inside of blood vessels and vasculature to organs of the

body and the heart. For a lower extremity angiography, a needle or catheter is

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DATE OF CLAIM CPT HCBP AMOUNT
SERVICE DATE CODE(S) | PROGRAM | CLAIMED
06/06//2018 | 06/08/2018 37225 CHP $21,752.00
06/14/2018 | 06/15/2018 37229 CHP $21,478.00
07/11/2018 | 07/19/2018 37225 CHP $21,752.00
07/19/2018 | 07/24/2018 37229 CHP $21,478.00

DEGRAFT-JOHNSON added SUR appointments to the EMR calendar for the June
14 and July 19 claims after the fact. AUSTIN then modified those appointments to
reflect a Visit Status of “Checked Out.” CHP paid DEGRAFT-JOHNSON
approximately $52,415.04 for these fraudulent claims.

55. The patient S.W. is a 61 year old female and UHC beneficiary.

a. According to S.W., she visited DEGRAFT-JOHNSON’s office
six times. She had one invasive procedure. Afterwards DEGRAFT-JOHNSON told
her that he had put a stent in her leg.

b. A review of EMR and UHC records for S.W. shows that
DEGRAFT-JOHNSON electronically signed operative reports falsely stating that
he had performed four atherectomies on S.W. and caused corresponding fraudulent

claims to UHC, for at least the second, third, and fourth atherectomy claims, as

follows:
DATE OF CLAIM CPT HCBP AMOUNT
SERVICE DATE CODE(S) | PROGRAM | CLAIMED
07/03/2018 07/03/2018 37229 UHC $21,478.00
07/12/2018 07/17/2018 37225 UHC $21,752.00
09/27/2018 10/04/2018 37229 UHC $21,478.00
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DEGRAFT-JOHNSON used the surveys to call patients, schedule consultations,
and use such patients to engage in the Four Step Fraud.

38. DEGRAFT-JOHNSON created duplicate calendar appointments and
wrote operative reports falsely stating he had performed atherectomies on dates
when he was not in the United States. AUSTIN knew that DEGRAFT-JOHNSON
was documenting those phantom surgeries when he was in fact abroad on the date
of service and routinely arranged to have DEGRAFT-JOHNSON’s EMR account
configured for international access. A review of claims from HVINF to Medicare
Part B, BCBS, Florida Medicaid FFS, CHP, Humana, Wellcare, Cigna and UHC
was performed for dates of service on which DEGRAFT-JOHNSON was traveling
out of the United States. DEGRAFT-JOHNSON billed a total of $6,055,291. These
health care benefit programs paid $2,343,668 in reimbursements for these fraudulent
claims.

39. For example, travel records establish that DEGRAFT-JOHNSON was
physically located in the Republic of Ghana on December 18, 19, and 20, 2018. On
this occasion, Employee 3 of Company A arranged to have DEGRAFT-
JOHNSON’s EMR account configured for international access. Subsequently
DEGRAFT-JOHNSON added SUR appoints to the EMR calendar, and completed
operative reports falsely claiming he had performed a total of 13 atherectomies on

patients (A.B. (x2), D.S., P.B., M.D., T.G., H.A., L.N., M.B., J.W., H.R., A.C., and

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DATE OF CLAIM CPT HCBP AMOUNT
SERVICE DATE CODE(S) | PROGRAM | CLAIMED
12/20/2016 | 02/16/2017 37229 Florida True | $5,000.00

37233 Health $2,500.00

08/23/2018 08/28/2018 37229 Florida True $5,000.00
Health

10/03/2018 10/04/2018 37229 Florida True $5,000.00

37233 Health $2,500.00

DEGRAFT-JOHNSON created after the fact SUR appointments for these dates of
service. AUSTIN modified the appointments for dates of service August 23 and
October 3, 2018, to reflect a Visit Status of “Checked Out.” Florida True Health paid
DEGRAFT-JOHNSON a total of $7,339.99 in reimbursements for these three
fraudulent claims.

48. The patient S.R. is a 59 year old female and BCBS beneficiary.

a. According to S.R., she was referred to DEGRAFT-JOHNSON
by her primary care physician in 2017 because of a rapid heartbeat. S.R. also suffers
from autoimmune disorder, severe COPD, and incontinence. DEGRAFT-
JOHNSON performed two angiograms on her legs in 2017. DEGRAFT-
JOHNSON told S.R. that she had a blockage which was too small to correct and
that they may be able to fix it with an ablation. When S.R. went to HVINF for the
ablation the ultrasound tech told her that DEGRAFT-JOHNSON ordered four
ablations and they were going to start on her right leg. After the ablations
DEGRAFT-JOHNSON told S.R. that a miracle had happened and that S.R.’s body
created a new vein to go around the blocked vein. Towards the end of 2019, S.R.

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direction, knowing that it was not a mistake even though it was not. DEGRAFT-
JOHNSON performed a second diagnostic angiogram on F.A. in July 2019. F.A.
returned for a follow up on August 1, 2019. DEGRAFT-JOHNSON wrote an
operative report related to this date, but subsequently instructed AUSTIN to delete
it. AUSTIN deleted the operative report as instructed. But when F.A. returned to
HVINF in October 2019, DEGRAFT-JOHNSON submitted another atherectomy
claim in order to avoid re-paying the health care benefit program for the fraudulent
Step 2 claim. Again, AUSTIN lied to F.A. with the false explanation that Company
A made a billing mistake.

43. Following that audit, Employee 5’s access to claim and billing
information in the EMR was terminated. When Employee 5 inquired, AUSTIN
falsely stated that Employee 5’s access to the billing information was an unnecessary
expense, when in truth there was no difference in costs associated with Employee 5
having access to claim and billing information in the EMR.

44. In August 2019, DEGRAFT-JOHNSON directed AUSTIN to
schedule each patient for four diagnostic angiographies. The purpose of performing
four diagnostic angiographies, rather than two, was to better conceal the fraudulent
scheme, as patients subjected to the scheme would remember having four procedures

rather than two. AUSTIN relayed this instruction to HVINF staff. Patients were

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DEGRAFT-JOHNSON added SUR appointments to the EMR calendar for the July
12 and September 27 claims after the fact. AUSTIN then modified the September
27 SUR appointment to reflect a Visit Status of “Checked Out.” UHC paid
DEGRAFT-JOHNSON approximately $28,505.16 for these three fraudulent
claims.
56. On October 19, 2018, DEGRAFT-JOHNSON traveled from New
York to Madrid, Spain. He returned to the United States, on October 31, 2018.
DEGRAFT-JOHNSON’s credit card records shows a $21,139.62 hotel charge and
a $61,473.81 charge at a department store, both located in Madrid, Spain. The EMR
calendar reflects DEGRAFT-JOHNSON’s absence from the HVINF office during
that period.
a. The patient L.S.W. is a 75 year old female and Medicare patient.
L.S.W. was scheduled for an established patient visit on October 23, 2018. On
November 7, 2018, DEGRAFT-JOHNSON added a SUR appointment to the
October 23, 2018, EMR calendar for L.S.W. DEGRAFT-JOHNSON also created
and electronically signed an operative report falsely stating that he performed an
atherectomy on L.S.W. on October 23, 2018. That same day, Company A billed
Medicare $21,478.00 under CPT code 37229, and $2,944.00 under CPT code 37233,
for this claim. On November 12, 2018, AUSTIN modified the SUR appointment to

show a “Visit Status” of “Checked Out.” Medicare paid DEGRAFT-JOHNSON

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gave a false explanation for this practice to Employee 5; that patients were cancelling
and rescheduling and Employee 5 was wasting paper.

31. AUSTIN made copies of surgery packets with undated, but signed,
consent forms for Steps 1 and 3. When patients returned to HVINF for follow up
visits on Steps 2 and 4, AUSTIN provided the duplicate packet to DEGRAFT-
JOHNSON. DEGRAFT-JOHNSON forged documents in the surgical packet to
make it appear as though he had actually performed a procedure. If there were a date
on the consent form (corresponding with the procedure previously performed),
DEGRAFT-JOHNSON directed AUSTIN to white out the previous date, and
AUSTIN did so. DEGRAFT-JOHNSON then directed that the forged surgical
packets be scanned into the EMR, and some were scanned into the EMR.

32. DEGRAFT-JOHNSON directed Company A and AUSTIN not to
charge copayments on Steps 2 and 4. The purpose of not collecting copayments on
Steps 2 and 4 was so that patients would not realize that DEGRAFT-JOHNSON
had submitted fraudulent claims (for Steps 2 and 4) to health care benefit programs.

33. _DEGRAFT-JOHNSON kept track of the number of atherectomies
billed for each patient. Employee 7 was a medical assistant working at HVINF.
Employee 7 would complete intake forms when patients returned to HVINF for
follow up appointments after a previous surgery. DEGRAFT-JOHNSON used the

back side of the forms as scratch paper for handwritten checklists (with boxes and

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a. Contrast induced nephropathy (CIN) is a well-recognized complication
of intravascular iodinated contrast administration. The greatest risk factor for CIN is
pre-existing renal dysfunction. The risk of CIN is elevated and becomes clinically
important when the baseline serum creatinine level is >=1.3 mg/dL (>=114.9
micromol/L) in men and >=1.0 mg/dL (<=88.4 micromol/L) in women, equivalent
to an estimated glomerular filtration rate (eGFR) <60 mL/min per 1.73 m. Elevations
in creatinine or decreases in GFR could theoretically be used as a valid reason for
minimizing the amount of interventional work at a given setting so as to mitigate the
risk of kidney injury. However, other modalities exist for mitigating CIN risk apart
from breaking a procedure into two separate procedures. Most notably, carbon
dioxide (CO2), a widely available gas in medical settings, can be used as a contrast
agent instead of iodinated contrast. Use of this agent, while somewhat more
burdensome than use of iodinated contrast, poses absolutely no risk to the kidneys
and is widely used when interventionalists have concern for CIN. Use of CO2
permits longer and more extensive interventional procedures to be performed despite
the presence of diminished renal function, therefore avoiding the risks associated
with a second invasive procedure.

b. DEGRAFT-JOHNSON was a provider for CHP. In December 2016,
CHP balked at paying certain atherectomy claims. CHP obtained a peer review of

patient G.H.’s case which observed that the operative notes stated there was a risk

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to reflect a Visit Status of “Checked Out.” Medicare paid DEGRAFT-JOHNSON
approximately $33,191.54 for these fraudulent claims.
53. The patient R.J.L. is a 71 year old male and Medicare beneficiary.

a. According to R.J.L., around the end of 2017 and the beginning
of 2018, his ankle started hurting when he played pickle ball. R.J.L went to a couple
of ankle doctors and was diagnosed with a vascular problem. R.J.L. was referred to
DEGRAFT-JOHNSON by another physician. R.J.L first saw DEGRAFT-
JOHNSON on February 2, 2018, for a new patient visit. A technician performed an
ablation which alleviated the pain. Sometime later, R.J.L bruised his inner thigh
bumping into a table. R.J.L. had an MRI which determined he only had a contusion,
but detected plaque in his iliac artery. DEGRAFT-JOHNSON subsequently
performed two procedures, one on each leg, and then follow up visits for each
procedure. After the first procedure, he was told that nothing had been found. R.J.L.
had follow up office visits after each diagnostic procedure, where no procedure was
performed. A review of the available images for a May 30, 2018, date of service
shows that R.J.L.’s condition was normal.

b. A review of EMR and Medicare records for R.J.L shows that
DEGRAFT-JOHNSON electronically signed operative reports falsely stating that
he had performed four atherectomies on R.J.L. and caused corresponding fraudulent

claims to Medicare, as follows:

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T.F.L. that she was fine. About one month later they returned for a second angiogram.
Again, it took about 20-30 minutes and was performed by DEGRAFT-JOHNSON.
When they returned for the follow-up DEGRAFT-JOHNSON told them both they
did not have any blockages but that they should wear compression hose.

b. A review of EMR and BCBS records for T.M.L and D.F.L.
shows that DEGRAFT-JOHNSON electronically signed operative reports falsely
stating that he had performed four atherectomies on T.F.L. and four atherectomies

on D.F.L., and caused corresponding fraudulent claims to BCBS, as follows:

DATE OF CLAIM PATIENT CPT HCBP AMOUNT
SERVICE DATE INITIALS | CODE(S) | PROGRAM | CLAIMED
11/21/2017 11/22/2017 T.M.L. 37225 BCBS $21,752.00
11/21/2017 11/22/2017 D.F.L. 37225 BCBS $21,752.00
11/27/2017 11/28/2017 T.M.L. 37229 BCBS $21,478.00
11/27/2017 11/28/2017 D.F.L 37229 BCBS $21,478.00
12/12/2017 12/13/2017 T.M.L. 37225 BCBS $21,752.00
12/12/2017 12/13/2017 D.F.L 37225 BCBS $21,752.00
12/21/2017 _| 12/23/2017 T.M.L. 37229 BCBS $21,478.00
12/21/2017 12/23/2017 D.F.L. 37229 BCBS $21,478.00

BCBS paid DEGRAFT-JOHNSON $106,386.32 in reimbursements for these
fraudulent claims. For each claim coded 37229, DEGRAFT-JOHNSON added a
SUR appointment to the EMR calendar after the fact. For the November 27, 2017,
date of service, AUSTIN then modified the appointments to reflect a Visit Status of
“Checked Out.” For the December 21, 2017, date of service, DEGRAFT-
JOHNSON added a total of fourteen SUR appointments to the EMR with
corresponding operative reports and fraudulent claims to health care benefit

programs.

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leg. CPT Code 37233 is an “add on” code when an atherectomy is performed on
multiple arteries in the leg.

14. Beginning in late 2015 or early 2016 until in or around August 2019,
DEGRAFT-JOHNSON engaged in a wide-ranging and consistent pattern of
performing two diagnostic angiographies—one on each leg—and each followed by
a follow-up office visit—and then billing health care benefit programs for four or
more atherectomies—when such procedures had not been performed.

15. In this pattern, with respect to a particular patient, the first fraudulent
claim (“Step 1”) was generally based on a diagnostic angiography which was
actually performed. But DEGRAFT-JOHNSON wrote and electronically signed an
operative report falsely stating that he performed an atherectomy on the patient’s
superficial femoral artery (either right or left) in the patient’s upper leg. Company A
would submit the claim to the applicable health care benefit program under CPT
Code 37225 for $21,752.00 based upon statements in the operative report. The key
phrase in the operative report supporting such a claim was this:

We utilized the [B]oston [S]cientific rotoblade artherectomy [sic]
device to perform atherectomy to the right superficial femoral artery.

16. For the second fraudulent claim (“Step 2”), the patient would return for
a follow-up visit several days later. Though he had not performed any procedure at
all, DEGRAFT-JOHNSON wrote and electronically signed an operative report

claiming that he performed an atherectomy on an artery or arteries in the patient’s

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inserted into the patient’s groin and passed into an artery followed by injection of
contrast material and imaging of the area in question. Among other things, this
procedure is used to detect the presence of peripheral artery disease (“PAD”). But,
according to applicable Medicare guidelines, “[w]ith modern noninvasive imaging
techniques . . . the need for invasive diagnostic angiography has been significantly
reduced. Currently, invasive angiography is mainly used to clarify contradictory
findings of noninvasive studies or in conjunction with therapeutic procedures.”
Legitimate lower extremity angiography is properly billed under CPT Codes 75710
and 75716. Medicare reimburses providers only a few hundred dollars for such a
diagnostic procedure.

13. A diagnostic angiography is sometimes followed by an atherectomy,
which is a procedure to open blocked coronary arteries or vein grafts by using a
device on the end of a catheter to cut or shave away atherosclerotic plaque (a deposit
of fat and other substances that accumulate in the lining of the artery wall).
Legitimate claims for lower extremity atherectomy procedures are properly billed
under CPT Codes 37225, 37227, and 37229. CPT Code 37225 relates to atherectomy
of the superficial femoral artery in the thigh. CPT 37227 relates to an atherectomy
on the femoral and/or popliteal arteries and includes the placement of a transluminal

stent. Code 37229 relates to atherectomy of the tibial or popliteal arteries in the lower

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check marks) for the 4-Step fraud on his patients. Employee 7 often saw patients
returning for follow up visits (Steps 2 and 4) and checked the patient’s groin area
and incision site to determine if the site was healing properly. DEGRAFT-
JOHNSON instructed AUSTIN when to call in patients for follow up visits so he
could bill for an atherectomy which he had not performed. AUSTIN scheduled the
patients as DEGRAFT-JOHNSON directed.

34. _DEGRAFT-JOHNSON had access to records and patient information
at Hospital B in Tallahassee, Florida. DEGRAFT-JOHNSON provided AUSTIN
with his log in credentials for Hospital B’s computer system and instructed AUSTIN
to print lists of Hospital B patients which were assigned to him for consulation.
AUSTIN printed the lists. DEGRAFT-JOHNSON instructed AUSTIN to contact
the patients and schedule them for appointments at HVINF. AUSTIN called the
patients and scheduled them for appointments. AUSTIN scratched out the patients
under 50 years of age and hospice patients. Most of the patients were never seen or
treated by DEGRAFT-JOHNSON prior to being called. AUSTIN asked Employee
2, a registered nurse, to call Hospital B patients. But Employee 2 refused.

35. AUSTIN also gave the patient lists to Employee 1, the HVINF
receptionist, and instructed Employee 1 to contact Hospital B patients for
appointments. AUSTIN instructed Employee | that if'a patient was reluctant to make

an appointment to transfer the patient to AUSTIN so AUSTIN could attempt to

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19. It is generally considered best practice, whenever performing an
atherectomy, to capture an angiographic image of the medical device in vivo to serve
as visual documentary evidence that an atherectomy was actually performed.
DEGRAFT-JOHNSON instructed Employee 2, a registered nurse working at
HVINF, not to record images of the device in use. Not recording said images led to
a lack of medical records showing atherectomies being actually performed in a small
number of cases and diagnostic angiographies in the vast majority of other instances.

20. DEGRAFT-JOHNSON often performed the — diagnostic
angiographies, whether medically necessary or not, so that he could falsely
document that he had performed an atherectomy, cause the submission of an up-
coded atherectomy claim, and obtain more money from health care benefit
programs. To justify performing the diagnostic angiography in the first place,
DEGRAFT-JOHNSON falsified test results in the patient’s medical records,
including the ankle brachial index (“ABI”). While the guidelines for management of
PAD allow for the use of invasive angiography for diagnostic purposes, performing
such a procedure without the proper indications represents a clear and substantial
deviation from the standard of care.

21. DEGRAFT-JOHNSON made false statements in his operative reports
and to health care benefit programs to justify claims that he performed multiple

atherectomies on a patient in successive fashion.

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AUSTIN modified the EMR calendar on five of these claims so the calendar would
show the patient had “Checked Out.” Diagnostic images available for dates of
service June 8 and July 5, 2016, and February 21 and June 20, 2017, show that N.S.
has a disease classification of mild, with no indication an atherectomy was
performed. WellCare paid DEGRAFT-JOHNSON $86,770.71 for these fraudulent
atherectomy claims related to N.S.

46. The patient R.C. is a 70-year old female and Medicare beneficiary. She
was referred to DEGRAFT-JOHNSON for swelling in her leg.

a. According to the patient, DEGRAFT-JOHNSON performed
two procedures on R.C., which R.C. recalls involving a needle or catheter being
inserted into her groin close to her “private parts.” R.C. returned to HVINF a week
after the first procedure. DEGRAFT-JOHNSON’s medical assistant inspected her
groin area during a brief appointment. R.C. returned to HVINF for a second
procedure, which took about 30 minutes to complete. A week later, R.C. returned to
HVINF for another inspection of her groin by DEGRAFT-JOHNSON’s medical
assistant. Following these procedures, her legs turned a darker color. DEGRAFT-
JOHNSON never gave her an explanation why.

b. A review of EMR records for R.C. shows that DEGRAFT-

JOHNSON electronically signed operative reports falsely stating he had performed

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IN THE UNITED STATES DISTRICT COURT
FOR THE NORTHERN DISTRICT OF FLORIDA
TALLAHASSEE DIVISION
UNITED STATES OF AMERICA
v. Case No. 4:20cr4-MW/MAF-1
MOSES D. DEGRAFT-JOHNSON,

Defendant.

STATEMENT OF FACTS

The Defendant MOSES D. DEGRAFT-JOHNSON admits that if this case
were to proceed to trial, the government could prove the following beyond a
reasonable doubt.

1. DEGRAFT-JOHNSON is a physician licensed to practice medicine
in the State of Florida under license number ME106359.

2. Between on or about September 21, 2015, and on or about February 13,
2020, DEGRAFT-JOHNSON owned and operated Thorvasc PA, a Florida
corporation doing business as the Heart and Vascular Institute of North Florida
(“HVINF”). HVINF was a physician’s office and outpatient catheterization

laboratory located in Tallahassee, Florida.

FILED IN OPEN COURT THIS
|2[[§/3030

CLERK, U.S. DISTRICT
COURT, NORTH. DIST. FLA.


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$10,404.77 for that claim. Medicare paid DEGRAFT-JOHNSON $29,098.19 for
three other atherectomy claims related to G.S.

b. The patient C.S.T. is a 70 year old female and CHP beneficiary.
C.S.T. had an established patient visit with a medical assistant at HVINF on March
12, 2019, while DEGRAFT-JOHNSON was abroad. On March 20, 2019,
DEGRAFT-JOHNSON added a SUR appointment to the March 12, 2019, EMR
calendar for C.S.T. and electronically signed an operative report falsely stating that
he had performed an atherectomy on C.S.T. on March 12, 2019. AUSTIN then
modified the SUR appointment to show a Visit Status of “Checked Out.”
DEGRAFT-JOHNSON caused Company A to bill CHP $21,478.00 for this
procedure under CPT Code 37229 and $2,944 for CPT code 37233. CHP paid
HVINF $12,947.28 for that claim. CHP paid DEGRAFT-JOHNSON a total
$46,713.27 for three other atherectomy claims related to C.S.T.

c. The patient I.S. is a 66 year old male and CHP beneficiary. IS.
had an established patient visit with a medical assistant at HVINF on March 12,
2019, while DEGRAFT-JOHNSON was abroad. On March 20, 2019, DEGRAFT-
JOHNSON added a SUR appointment to the March 12, 2019, EMR calendar for
LS. and electronically signed an operative report falsely stating that he had
performed an atherectomy on I.S. on March 12, 2019. AUSTIN then modified the

SUR appointment to show a Visit Status of “Checked Out.” DEGRAFT-

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perform GFR calculations. Under the guidance of Company A, DEGRAFT-
JOHNSON falsely stated in his operative reports that he had utilized the i-STAT
device to determine serum creatinine and GFR level.

h. In a letter to CHP dated February 7, 2017, DEGRAFT-JOHNSON
falsely stated that he followed a “protocol for prophylaxis strategies for contrast-
induced nephropathy” and “[flor every patient we encounter we utilize . . . [t]he
Abbot I-Stat system to obtain objective quantification such as serum creatinine
levels and GFR which is the best metric for renal function.”

i. On December 17, 2018, CHP sent another letter to DEGRAFT-
JOHNSON stating concerns about his four-step sequence of atherectomy
procedures as stated in his operative reports; that “multiple procedures were
performed within a short window of time and that ultimately the procedures were
not medically necessary.” CHP provided DEGRAFT-JOHNSON peer review
reports about three patients and asked DEGRAFT-JOHNSON to respond to each
reviewer’s concerns. The patient B.M.W. was included in the review. In the summer
of 2016, DEGRAFT-JOHNSON had performed two medically unnecessary
angiograms on B.M.W., billed CHP for four atherectomies, and was paid $53,365.

j. In a letter dated February 5, 2019, DEGRAFT-JOHNSON falsely
stated that the procedures could not have been combined because he had run a test

showing the “objective quantification for the risk of contrast-induced nephropathy.”

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of “contrast-induced nephropathy” but there was no “objective quantification of this
risk.”

c. On or about January 5, 2017, an Abbott i-STAT device was actually
shipped to DEGRAFT-JOHNSON from an acquaintance in Jamaica at
DEGRAFT-JOHNSON’s request, after DEGRAFT-JOHNSON left the device
there upon completion of a surgery

d. On January 19, 2017, CHP sent DEGRAFT-JOHNSON a letter
stating that an external peer review of his surgery records found that “there did not
appear to be a medical reason behind performing the procedures on consecutive
days.”

e. On February 1, 2017, DEGRAFT-JOHNSON printed an article
regarding contrast-induced nephropathy and highlighted the risk factors for it.

f. Beginning on February 1, 2017, and continuing thereafter,
DEGRAFT-JOHNSON falsely stated in each operative report “The Abbott I-stat
system was utilized to determine the patient's risk for contrast induce nephropathy.”

g. | DEGRAFT-JOHNSON did not actually use the i-STAT as stated in
his operative reports. During a search of HVINF on February 13, 2020, the i-STAT
device was found in a box in a closet, along with documents showing it shipped from
Jamaica in January 2017. Moreover, the i-STAT device is not capable of performing

GFR calculations. Instead, DEGRAFT-JOHNSON utilized an app on his phone to

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that he had performed an atherectomy on D.H. on January 15, 2019. AUSTIN then
modified the SUR appointment to show a Visit Status of “Checked Out.”
DEGRAFT-JOHNSON caused Company A to bill CHP $21,478.00 for this
procedure under CPT Code 37229 and $2,944 for CPT code 37233. Medicare paid
HVINF $10,404.77 for that claim.
60. DEGRAFT-JOHNSON traveled to the Republic of Ghana on

February 8, 2019. He returned to the United States on February 17, 2019.

a. D.H. had an established patient visit with a medical assistant at
HVINF on February 12, 2019, while DEGRAFT-JOHNSON was abroad. On
March 12, 2019, DEGRAFT-JOHNSON added a SUR appointment to the February
12 EMR calendar for D.H. and electronically signed an operative report falsely
stating that he had performed an atherectomy on D.H. on February 12, 2019.
AUSTIN then modified the SUR appointment to show a Visit Status of “Checked
Out.” DEGRAFT-JOHNSON caused Company A to bill CHP $21,478.00 for this
procedure under CPT Code 37229 and $2,944 for CPT code 37233. Medicare paid
HVINF $10,404.77 for that claim. Medicare paid DEGRAFT-JOHNSON a total of
$39,390.37 for a total of four atherectomy claims related to D.H.

b. The patient E.W. is a 58 year old female and BCBS beneficiary.
According to E.W., she was referred to DEGRAFT-JOHNSON for numbness on

the bottom of her foot. DEGRAFT-JOHNSON performed two procedures

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that hers had a road block and needed a detour. J.F.D.P returned for two procedures
which DEGRAFT-JOHNSON described as a “roto-rooter.”. DEGRAFT-
JOHNSON performed one procedure on each leg. Each procedure lasted about 15
minutes. A review of the available images for these two procedures revealed no
vascular disease in one leg, a mild condition in the other, and no evidence of an
atherectomy being performed. Following these procedures, DEGRAFT-
JOHNSON told J.F.D.P. he had done all he could for her and that he could not do
anything more to help her. Her legs continued to hurt. Another physician
subsequently performed ablations on J.F.D.P.’s legs. Those ablation procedures
alleviated J.F.D.P.’s pain.

b. A review of EMR and Medicare records for J.F.D.P. shows that
DEGRAFT-JOHNSON electronically signed operative reports falsely stating that
he had performed four atherectomies on J.F.D.P and caused corresponding

fraudulent claims to Medicare, as follows:

DATE OF CLAIM CPT HCBP AMOUNT
SERVICE DATE CODE(S) | PROGRAM | CLAIMED
04/10/2018 | 04/10/2018 37225 Medicare $21,752.00
04/19/2018 | 04/23/2018 37229 Medicare $21,478.00

03/05/2019 | 03/06/2019 37225 Medicare $21,752.00
05/08/2018 | 05/10/2018 37229 Medicare $21,478.00

DEGRAFT-JOHNSON added SUR appointments to the EMR calendar for the

April 19 and May 8 claims after the fact. AUSTIN then modified the appointments

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JOHNSON caused Company A to bill CHP $21,752.00 for this procedure under
CPT Code 37225. CHP paid HVINF $11,626.70 for that claim. CHP paid
DEGRAFT-JOHNSON a total of $37,521.26 for three other atherectomy claims
related to I.S.

d. The patient R.S. is a 76 year old male and BCBS beneficiary.
R.S. had an established patient visit with a medical assistant at HVINF on March 13,
2019, while DEGRAFT-JOHNSON was abroad. On March 20, 2019, DEGRAFT-
JOHNSON added a SUR appointment to the March 13, 2019, EMR calendar for
R.S. and electronically signed an operative report falsely stating that he had
performed an atherectomy on R.S. on March 13, 2019. AUSTIN then modified the
SUR appointment to show a Visit Status of “Checked Out.” DEGRAFT-
JOHNSON caused Company A to bill BCBS $21,478.00 for this procedure under
CPT Code 37229 and $5,888.00 for CPT code 37233. BCBS paid HVINF
$16,638.57 for that claim. BCBS paid DEGRAFT-JOHNSON a total of $13,042.03
for one other atherectomy claim related to R.S.

63. The patient T.D. is a 57 year old female and Medicare beneficiary.

a. T.D. was referred by her primary care practitioner to
DEGRAFT-JOHNSON regarding a bulge in T.D.’s aorta) DEGRAFT-
JOHNSON told T.D. that he wanted to conduct procedures in her legs to determine

if she had any blockages. DEGRAFT-JOHNSON performed two diagnostic

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50. In March 2018, DEGRAFT-JOHNSON and his spouse were
participating in an executive MBA program offered by Brown University. In his
application DEGRAFT-JOHNSON stated “[a]fter 17 years of practicing medicine,
I’m ready to return back home to Ghana.” DEGRAFT-JOHNSON paid the tuition
and associated expenses from funds in the HVINF bank accounts. Part of the program
involved two weeks of coursework in Madrid, Spain, in March of 2018. Travel
records establish that DEGRAFT-JOHNSON was on a flight to Spain on March 2,
2018, and returned to the United States on March 17, 2018.

51. The patient L.D. is an 88 year old female and WellCare beneficiary.
L.D. had an established patient visit with a medical assistant at HVINF on March 12,
2018, while DEGRAFT-JOHNSON was abroad. On March 21, 2018, DEGRAFT-
JOHNSON added a SUR appointment to the March 12 EMR calendar for L.D. and
electronically signed an operative report falsely stating that he had performed an
atherectomy on L.D. on March 12, 2018. DEGRAFT-JOHNSON caused Company
A to bill WellCare $21,478.00 for this procedure under CPT Code 37229. WellCare
paid HVINF $8,402.07 for that claim.

52. The patient J.F.D.P. is a 75 year old female and Medicare beneficiary.

a. According to J.F.D.P., she was referred to HVINF by her primary
care doctor for severe pain in her legs. During an initial visit, DEGRAFT-

JOHNSON told J.F.D.P. that her veins were like Capital Circle in Tallahassee and

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lower leg. To generate the operative report, DEGRAFT-JOHNSON had to create
a second appointment for the patient on the electronic calendar in HVINF’s web-
based electronic medical records system (“EMR”). Company A would submit the
claim to the applicable health care benefit program under CPT Code 37229 for
$21,478.00. If the Step 2 operative report described atherectomy of multiple arteries,
the claim would also include the add-on CPT code 37233 for $2,944.

17. The third and fourth fraudulent claims (Steps 3 and 4) are a repeat of
this process on the patient’s other leg. Thus, for each manifestation of this 4-Step
scheme, there were two fraudulent up-coded claims (from a diagnostic angiogram to
an atherectomy, Steps 1 and 3) and two phantom atherectomy claims (Steps 2 and
4) where no procedure was performed. For some patients, DEGRAFT-JOHNSON
engaged in this 4-Step process multiple times.

18. DEGRAFT-JOHNSON maintained residence in New York.
DEGRAFT-JOHNSON customarily traveled to Tallahassee, Florida via
commercial airline on Mondays. DEGRAFT-JOHNSON performed procedures on
Monday afternoons, Tuesdays, and Wednesdays. DEGRAFT-JOHNSON had
office visits with patients on Thursday mornings. DEGRAFT-JOHNSON rarely
performed surgeries on Thursdays or Fridays. Because office visits were held on
Thursdays, including follow-up visits, many of the Step 2 and Step 4 claims were

billed for Thursday dates of service.

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O.L.) on December 18, 19, and 20, 2018. AUSTIN subsequently modified the Visit
Status for each SUR appointment to green to reflect the patient was “Checked Out.”

This is a redacted image of the EMR calendar for December 19, 2018:

40. Employee 5 brought these December 2018 phantom surgeries to
AUSTIN ’s attention. AUSTIN responded that Employee 5 did not understand how
insurance worked, that this was part of the billing “bundle,” that Employee 5’s job
was just to schedule surgeries, and Employee 5 needed to tend to that job.

41. In or around August 2019, DEGRAFT-JOHNSON subsequently
modified the scheme. The reason for this modification was an audit by a health care
benefit program and the experience of patient FA, who was a HVINF patient in
2019.

42. In July 2019, F.A. complained to DEGRAFT-JOHNSON that her
insurance company had been double billed; two procedures when the latter visit
(Step 2) to HVINF was merely a follow up visit to one procedure (Step 1).
DEGRAFT-JOHNSON relayed this complaint to AUSTIN. AUSTIN lied to F.A.

with the explanation that the billing was a mistake. AUSTIN complied with that

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COUNTS TWO THROUGH FIFTY-SEVEN (18 U.S.C. §1347) -—
Health Care Fraud

(1) the Defendant knowingly executed, or attempted to execute, a scheme or
artifice to defraud a health-care benefit program, or to obtain money or
property owned by, or under the custody or control of, a health-care
benefit program by using false or fraudulent pretenses, representations,
or promises;

(2) the health care benefit program affected interstate commerce;

(3) the false or fraudulent pretenses, representations, or promises related to a
material fact;

(4) the Defendant acted willfully and intended to defraud; and

(5) the Defendant did so in connection with the delivery of or payment for
health-care benefits, items, or services.

COUNT FIFTY-EIGHT (18 U.S.C. §1028A) —
Aggravated Identity Theft

(1) the Defendant knowingly transferred, possessed, or used
another person’s means of identification;

(2) without lawful authority; and
(3) during and in relation to the scheme to defraud Medicare

alleged in Counts Thirteen, Sixteen, Seventeen, and Nineteen of
the Indictment.

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57. The patient M.K.W. is a 65 year old female and WellCare beneficiary.
a. According to M.K.W., she was referred to DEGRAFT-
JOHNSON for “hurting in her chest.” DEGRAFT-JOHNSON saw M.K.W. in his
office between 15 and 20 times. DEGRAFT-JOHNSON performed a total of four
angiograms on four separate days. There were follow up examinations conducted by
a nurse. DEGRAFT-JOHNSON told M.K.W. that she had no blockages in her
arteries. The procedures did not alleviate M.K.W.’s pain.
b. A review of EMR and WellCare records for M.W.K. shows that
DEGRAFT-JOHNSON electronically signed operative reports falsely stating that
he had performed eight atherectomies on M.K.W. and caused corresponding

fraudulent claims to WellCare, as follows:

DATE OF CLAIM CPT HCBP AMOUNT
SERVICE DATE CODE(S) | PROGRAM | CLAIMED
09/25/2018 | 09/27/2018 37225 WellCare | $21,752.00
10/17/2018 10/18/2018 37229 WellCare | $21,478.00
37233 $2,944.00
11/02/2018 11/6/2018 37225 WellCare | $21,752.00
11/13/2018 11/20/2018 37229 WellCare | $21,478.00
37233 $2,944.00
07/23/2019 | 07/25/2019 37225 WellCare__| $21,752.00
08/01/2019 | 08/06/2019 37229 WellCare __| $21,478.00
08/06/2019 | 08/08/2019 37225 WellCare | $21,752.00
08/15/2019 | 08/21/2019 37229 WellCare | $21,478.00

DEGRAFT-JOHNSON added SUR appointments to the EMR calendar for the
October 17 and November 13, 2018, claims, and the August | and August 15, 2019,
claims after the fact. AUSTIN then modified those appointments to reflect a Visit

Status of “Checked Out.” Additionally, DEGRAFT-JOHNSON was in the

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Republic of Ghana on November 13, 2018. WellCare paid DEGRAFT-JOHNSON
approximately $80,910.48 for these fraudulent claims.
58. The patient C.S. is a 67 year old male and Medicare beneficiary.

a. C.S. suffers from severe mental illness, including schizophrenia
(manic depressive) and bipolar disorder. C.S. lacks the capacity to understand or
recall events. The sister of C.S. serves as his Medicaid Certified Caretaker (“MCC”).
According to the MCC, DEGRAFT-JOHNSON treated C.S. for circulatory
problems. MCC accompanied C.S. to appointments. DEGRAFT-JOHNSON
performed a procedure on C.S. involving a stent at a local hospital.

b. A review of EMR and Medicare records for C.S. shows that
DEGRAFT-JOHNSON electronically signed operative reports falsely stating that
he had performed four atherectomies on C.S. at HVINF and caused corresponding

fraudulent claims to Medicare, as follows:

DATE OF CLAIM CPT HCBP AMOUNT
SERVICE DATE CODE(S) | PROGRAM | CLAIMED
10/03/2018 10/15/2018 37225 Medicare _| $21,752.00
11/01/2018 11/07/2018 37229 Medicare | $21,478.00
37233 $2,944.00
11/06/2018 11/07/2018 37225 Medicare | $21,752.00
11/13/2018 11/13/2018 37229 Medicare | $21,478.00
37233 $2,944.00

On November 9, 2018, DEGRAFT-JOHNSON traveled to the Republic of Ghana.
He returned to the United States on November 17, 2018. DEGRAFT-JOHNSON

was not physically present in the United States on the November 13, 2018, date of

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DEGRAFT-JOHNSON then traveled to Tallahassee, Florida, on December 19,
2019. The patient R.H. is an 80 year old male and an Aetna beneficiary. On
December 17, 2019, R.H. had an established patient visit with a medical assistant at
HVINF while DEGRAFT-JOHNSON was abroad. On January 10, 2020,
DEGRAFT-JOHNSON added a SUR appointment to the December 17, 2019,
EMR calendar for R.H. and electronically signed an operative report falsely stating
that he had performed an atherectomy on R.H. on December 17, 2019. AUSTIN
then modified the SUR appointment to show a Visit Status of “Checked Out.”
DEGRAFT-JOHNSON caused Company A to bill Aetna $21,752.00 for this
procedure under CPT Code 37229. Aetna paid HVINF $11,679.89 for that claim.
Aetna paid DEGRAFT-JOHNSON a total of $36,699.91 for three other
atherectomy claims related to R.H. in late 2019 and early 2020. Previously,
DEGRAFT-JOHNSON submitted four additional atherectomy claims related to
R.H to Medicare for dates of service March 29, 2016, May 9, 2016, and March 8,
2017. The March 8, 2017, operative note describes an atherectomy of the right
superficial femoral artery with a standard left groin puncture and “up and over”
access to the right superficial femoral artery. Because R.H. had an endovascular
aneurysm repair on May 24, 2016, with a Medtronic Endurant device, which
advances the aortic bifurcation, the procedure as described in DEGRAFT-

JOHNSON ’s March 8, 2017, operative report is technically impossible to perform.

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needed a refill on her heart medicine. DEGRAFT-JOHNSON told S.R. that he
would need to do more angiograms to determine which medicine would be best for
her. DEGRAFT-JOHNSON told S.R. that the laws had recently changed and that
he could not use as much dye as he did before and that he would have to do four
angiograms instead of two. During November and December of 2019, S.R. had four
angiograms performed by DEGRAFT-JOHNSON. After those procedures,
DEGRAFT-JOHNSON told S.R. that he did not find any blockages. During each
angiogram, DEGRAFT-JOHNSON put a catheter in through S.R.’s groin.
Subsequently, S.R. saw a new vascular doctor and cardiologist. The vascular doctor
performed an ultrasound and told S.R. that she had some peripheral artery disease
but that it was not severe. S.R. later saw some of her medical records from
DEGRAFT-JOHNSON and saw that he said he had performed several
atherectomies and balloon angioplasties. S.R. became upset because she knew this
was not true.

b. A review of EMR and BCBS records for S.R. shows that
DEGRAFT-JOHNSON electronically signed operative reports falsely stating that
he had performed eight atherectomies on S.R. and caused corresponding fraudulent

claims to BCBS, as follows:

DATE OF CLAIM CPT HCBP AMOUNT

SERVICE DATE CODE(S) | PROGRAM | CLAIMED

11/06/2017 11/07/2017 37225 BCBS $21,752.00

11/13/2017 11/14/2017 37229 BCBS $21,478.00

11/29/2017 11/29/2017 37225 BCBS $21,752.00
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Aetna $256,257.72 $246,222.59 96%
Cigna $52,859.67 $44,050.48 83%
Totals $36,834,783.00 | $33,837,919.48 88%

This table does not include reimbursement payments from several health care benefit
programs for approximately 203 atherectomy primary claim submissions.

74. DEGRAFT-JOHNSON generally utilized Synovus Bank account
ending in *4135 (“Synovus *4135”) as the primary “deposit” account for all
healthcare-related funds flowing to HVINF from health care benefit programs.
Synovus *4135 is held in the name of Thorvasc PA DBA HVINF. DEGRAFT-
JOHNSON was the sole signer on the account. Between November 1, 2015, and
February 13, 2020, health care benefit programs paid HVINF approximately
$37,713,833.71. DEGRAFT-JOHNSON used these funds to acquire property
described in CM/ECF document 95-1, an asset list attached to the Government’s
Notice of Bill of Particulars, ECF No. 95, which are hereby incorporated by
reference into this Statement of Facts.

ELEMENTS

COUNT ONE (18 U.S.C. §1349) —
Conspiracy to Commit Health Care Fraud

(1) that two or more people in some way agreed to accomplish a shared
unlawful plan to commit health care fraud, as charged in the indictment;
and

(2)the Defendant knew the unlawful purpose of the plan and willfully joined
it.

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Title XIX of the Social Security Act, Chapter 409, Florida Statutes, and Chapter
59G, Florida Administrative Code. Florida Medicaid is financed with both federal
and state funds, and was a “health care benefit program” as defined by Title 18,
United States Code, Section 24(b). The Agency for Health Care Administration
(“AHCA”) was a State of Florida agency responsible for Florida Medicaid. Each
Florida Medicaid recipient was issued a unique ID number (“Medicaid recipient ID
number”) by AHCA, which was used in the submission of Florida Medicaid claims,
determination of Florida Medicaid eligibility, and for processing and adjudicating
Florida Medicaid claims. Under Florida Medicaid, a Florida Medicaid provider
(“Provider”) was a person, organization, or institution having a written agreement
with the State of Florida and its Managed Care Organizations (“MCOs”) to: (1)
provide services to recipients, (2) submit claims for services rendered, and (3) accept
as payment in full the amount paid by Florida Medicaid for submitted claims.
Providers were required to possess and maintain a valid professional license
pertinent to the services they were providing to Florida Medicaid recipients, and
were required to comply with all applicable rules and regulations. Each provider
was issued a manual or was provided with online access to regulations outlining
participation requirements and guidelines. Each provider was issued a unique
Florida Medicaid ID number (“Medicaid provider ID number”) by AHCA which

was used in the submission, processing, and payment of Florida Medicaid claims.

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02/26/2019 | 02/27/2019 37225 BCBS $21,752.00
02/28/2019 | 03/03/2017 37229 BCBS $21,478.00
37233 $2,942.00
03/05/2019 | 03/06/2019 37225 BCBS $21,752.00
03/12/2019 | 03/21/2019 37229 BCBS $21,478.00
37233 $2,942.00

DEGRAFT-JOHNSON added SUR appointments to the EMR calendar for the
February 28 and March 12 claims after the fact. AUSTIN then modified the
appointments to reflect a Visit Status of “Checked Out.” DEGRAFT-JOHNSON
was physical located in the Republic of Ghana on March 12, 2019. BCBS paid
DEGRAFT-JOHNSON approximately $55,569.98 in reimbursements for these
fraudulent claims.

62. On March 8, 2019, DEGRAFT-JOHNSON traveled to the Republic
of Ghana. He returned to the United States on March 19, 2019.

a. The patient G.S. is a 68 year old female and Medicare
beneficiary. G.S. had an established patient visit with a medical assistant at HVINF
on March 11, 2019, while DEGRAFT-JOHNSON was abroad. On March 20, 2019,
DEGRAFT-JOHNSON added a SUR appointment to the March 11 EMR calendar
for G.S. and electronically signed an operative report falsely stating that he had
performed an atherectomy on G.S. on March 11, 2019. AUSTIN then modified the
SUR appointment to show a Visit Status of “Checked Out.” DEGRAFT-
JOHNSON caused Company A to bill Medicare $21,478.00 for this procedure

under CPT Code 37229 and $2,944 for CPT code 37233. Medicare paid HVINF

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involving the insertion of a catheter or needle into her groin which took less than
fifteen minutes. After the procedures, DEGRAFT-JOHNSON told her she had no
blockages. After each procedure, and saw the medical assistant to make sure the
incision site was healing. DEGRAFT-JOHNSON ordered an MRI for E.W. but she
could not afford the co-pay and did not have it done. E.W. never heard from
DEGRAFT-JOHNSON’s office again. E.W. still has numbness in her foot. E.W.
had an established patient visit with a medical assistant at HVINF on February 15,
2019, while DEGRAFT-JOHNSON was abroad. On February 18, 2019,
DEGRAFT-JOHNSON added a SUR appointment to the February 12, 2019, EMR
calendar for E.W. and electronically signed an operative report falsely stating that
he had performed an atherectomy on E.W. on February 15, 2019. AUSTIN then
modified the SUR appointment to show a Visit Status of “Checked Out.”
DEGRAFT-JOHNSON caused Company A to bill CHP $21,478.00 for this
procedure under CPT Code 37229 and $2,944 for CPT code 37233. BCBS paid
HVINEF $14,822.96 for that claim. DEGRAFT-JOHNSON caused the submission
of three other fraudulent atherectomy claims related to E.W. on dates of service
February 5, February 18, and February 20, 2020. Images available for the February
5 and February 18 dates of service show that E.W.’s condition was normal. BCBS
paid DEGRAFT-JOHNSON a total of $55,789.98 for these four fraudulent

atherectomy claims related to E.W.

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billed in the amount of $21,478.00. Claims including the add-on CPT Code 37233
were billed an additional $2,944.00.

25. Employee 4 worked as radiation technologist at HVINF from in or
around September 2016 until in or around June 2017. Employee 4 assisted
DEGRAFT-JOHNSON during procedures. Employee 4 noticed that DEGRAFT-
JOHNSON included details in his operative reports which Employee 4 did not
remember occurring. Employee 4 noticed many times that DEGRAFT-JOHNSON
had documented an atherectomy having occurred the previous visit when Employee
4 knew that DEGRAFT-JOHNSON had only performed an angiogram. Employee
4 began to print these records, highlighted the incorrect information, and gave these
records to AUSTIN. AUSTIN told Employee 4 that DEGRAFT-JOHNSON used
a pre-written procedure report template in which he had to just fill in some blanks.
AUSTIN falsely stated to Employee 4 that DEGRAFT-JOHNSON sometimes
forgot to take out details that did not happen from the templates. AUSTIN
sometimes said that DEGRAFT-JOHNSON also mixed up the patients he was
documenting. Employee 4 brought this to AUSTIN’s attention at least three times.
When Employee 4 resigned from HVINF, Employee 4 told AUSTIN that she was
quitting because Employee 4 knew that DEGRAFT-JOHNSON was a “crook.”

26. Employee 2 worked as a registered nurse at HVINF from late 2015 to

early 2016, and from October 2016 to May 2019. When Employee 2 returned to

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72. Analysis of purchase records establishes that DEGRAFT-JOHNSON
obtained atherectomy devices sufficient to perform approximately 528
atherectomies. A CPT code report generated from the EMR establishes that
DEGRAFT-JOHNSON caused the submission of claims to health care benefit
programs for 3,542 distinct atherectomy procedures relating to 845 HVINF patients.
DEGRAFT-JOHNSON could not have performed approximately 3,014, or 85%,
of the atherectomy procedures he claimed to have performed.

73. The CPT code report and health care benefit program records establish
that these 3,542 atherectomy claims were submitted to 38 health care benefit
programs in 5,141 submissions (some claims were submitted to both a primary,
secondary, or tertiary payer). Some of those health care benefit programs paid
DEGRAFT-JOHNSON approximately $33,837,919.48 for these atherectomy

claims according to the following table.

Healthcare benefit | Total paid for | Total paid for | Percentage

programs all services atherectomy | of total paid
billed by Dr. claims (37225, for

deGraft- 37227, 37229, | atherectomy

Johnson and 37233) claims
Medicare $12,787,447.86 | $11,688,266.60 91%
CHP $7,665,878.20 | $7,363,891.67 96%
BCBS $5,242,822.61 | $4,706,512.34 89%
WellCare $4,805,226.55 | $4,394,054.97 91%
UHC $3,673,461.62 | $3,342,931.25 91%
Humana $1,389,699.55 | $1,291,394.96 93%
Florida True Health $481,813.52 $411,974.62 85%
Tricare $479,315.70 $348,620.00 72%
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28. AUSTIN maintained an Excel spreadsheet titled “Angios” that tracked
the dates of diagnostic angiographies which were actually performed. AUSTIN
maintained this spreadsheet for AUSTIN’s own reference document for the
procedures which were actually performed by DEGRAFT-JOHNSON in case a
patient, external physician, hospital, or insurance company inquired about a
particular procedure. AUSTIN utilized the spreadsheet to make knowingly false
statements to patients and thereby conceal and further the fraudulent scheme.

29. For procedures actually performed, there were “surgery packets”
prepared in advance by HVINF employees. A surgery packet included consent
forms, pre-procedural “time-out” forms, pre-operative orders, intra-procedural vital
sign monitoring forms, medication administration logs, surgical logs, and post-
procedural prescriptions. Employee 6, of Company A, learned that, while
DEGRAFT-JOHNSON claimed to have performed four surgeries, there would
only be two surgery packets; one surgery packet for each leg (Steps 1 and 3).
Employee 6 advised DEGRAFT-JOHNSON that he needed a surgery packet for
each procedure, with a patient signature.

30. Beginning in approximately 2016, DEGRAFT-JOHNSON directed
AUSTIN to leave the date field blank in the surgery packets for Steps 1 and 3 when
patients signed the informed consent forms prior to obtaining a procedure. AUSTIN

directed other employees to leave the date blank on the consent forms. AUSTIN

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done in a qualified medical center without the need for an overnight stay. First Coast
Service Options, Inc. (“FCSO”), located in Jacksonville, Florida, was the fiscal
agent that processed the claims and maintained the records for the Medicare
program in Florida. One of the critical conditions for any payment was that the
service had actually been provided for a legitimate, medically necessary purpose.
Medicare only reimburses services that were medically necessary and actually
rendered.

7. The TRICARE Program (TRICARE) was a “health care benefit
program,” as defined by Title 18, United States Code, Section 24(b), of the United
States Department of Defense Military Health System, which affected commerce.
TRICARE provided coverage for DOD beneficiaries worldwide, including active
duty service members, National Guard and Reserve members, retirees, their families,
and survivors. Individuals who received health care benefits through TRICARE
were referred to as TRICARE beneficiaries. The Defense Health Agency (“DHA”),
an agency of the DOD, was responsible for overseeing and administering the
TRICARE program.

8. The Florida Medicaid Program (“Florida Medicaid”) was a partnership
between the State of Florida and the federal government that provided medical
assistance and healthcare coverage to eligible low-income Florida families and

individuals (“Florida Medicaid recipients”). Florida Medicaid was authorized by

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30, 2018. AUSTIN modified the SUR appointment to show a “Visit Status” of
“Checked Out.” On November 2, 2018, Company A billed Medicare $21,752.00
under CPT code 37225, for this claim. Medicare paid DEGRAFT-JOHNSON
$8,352.25 for this fraudulent claim.

d. The patient N.M. is a 63 year old female and a WellCare
beneficiary. N.M was scheduled for an established patient visit on October 30, 2018.
On November 7, 2018, DEGRAFT-JOHNSON added a SUR appointment to the
EMR calendar for N.M. DEGRAFT-JOHNSON also created and electronically
signed an operative report falsely stating that he performed an atherectomy on N.M.
on October 26, 2018. That same day, Company A billed Medicare $21,478.00 under
CPT code 37229, and $2,944.00 under CPT code 37233, for this claim. On
November 12, 2018, AUSTIN modified the SUR appointment to show a “Visit
Status” of “Checked Out.” WellCare paid DEGRAFT-JOHNSON $2,250.19 for
this fraudulent claim. WellCare paid DEGRAFT-JOHNSON a total of $15,975.74
for the eight atherectomies which DEGRAFT-JOHNSON claimed to have
performed on N.M. Images available for diagnostic angiographies performed on
August 8, 2017, and September 20, 2017, shows N.M.’s condition as normal. It
would have been impossible for significant atherosclerotic occlusive disease to have
developed between September 2017 and October 2018, as development of

atherosclerosis is an indolent, slow-moving process.

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eight atherectomies on R.C. Omitting the first and third claims, the remaining six

fraudulent atherectomy claims are as follows:

DATE OF CLAIM CPT HCBP AMOUNT
SERVICE DATE CODE(S) | PROGRAM | CLAIMED
11/29/2016 12/01/2016 37229 WellCare $21,478.00

37233 $2,944.00
12/19/2016 12/20/2016 37229 Medicare $21,478.00
37233 $2,944.00
10/09/2018 10/17/2018 37225 Medicare $21,752.00
10/16/2018 10/18/2018 37229 Medicare $21,478.00
37233 $2,944.00

10/17/2018 10/18/2018 37225 Medicare $21,752.00
11/01/2018 11/07/2018 37229 Medicare $21,478.00
37233 $2,944.00

AUSTIN modified the EMR calendar on four of these claims so the calendar would
show the patient had “Checked Out.” For the first of these six claims, WellCare paid
DEGRAFT-JOHNSON $9,730. For the last five claims, Medicare paid
DEGRAFT-JOHNSON $53,465.28.

47. The patient C.A. is a 65 year old female and Florida True Health
beneficiary.

a. According to C.A.. DEGRAFT-JOHNSON performed two
procedures on C.A. involving stents in her right leg. A review of EMR records for
C.A. shows that DEGRAFT-JOHNSON electronically signed operative reports
falsely stating that he had performed six atherectomies on C.A. Conservatively
omitting the three odd numbered procedures, the remaining three fraudulent

atherectomy claims are as follows:

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3. KIMBERLY AUSTIN was the office manager at HVINF.
DEGRAFT-JOHNSON paid AUSTIN a salary of approximately $100,000 per
year.

4. Company A, operating in the Northern District of Florida, was engaged
in the business of billing health care benefit programs on behalf of medical providers
including HVINF. At Defendants’ direction, Company A submitted claims to health
care benefit programs on behalf of HVINF. Company A received a 6% commission
from collections it obtained for HVINF.

5. The term “health care benefit program” as defined in Title 18, United
States Code, Section 24, means any public or private plan or contract, affecting
commerce, under which any medical benefit, item, or service is provided to any
individual, and includes any individual or entity who is providing a medical benefit,
item, or service for which payment may be made under the plan or contract.

6. The Medicare program is a federal health care program providing
benefits to persons who were over the age of 65 or disabled. Medicare was a “health
care benefit program” as defined by Title 18, United States Code, Section 24(b),
which affected commerce. Medicare was administered by the Centers for Medicare
and Medicaid Services (CMS), a federal agency under the United States Department
of Health and Human Services. Medicare was funded by federal tax dollars.

Medicare Part B covered outpatient services, meaning procedures or tests that are

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angiographies on T.D.; one on each leg. According to T.D., the procedures consisted
of staff shaving the area of her groin and DEGRAFT-JOHNSON inserting a needle
with a camera to look for blockages in her lower extremities. T.D. did not have any
blockages. T.D. had three follow up visits where no procedure was performed. For
several of these visits, DEGRAFT-JOHNSON was not present in the HVINF
office.

b. A review of EMR and Medicare records for T.D. shows that
DEGRAFT-JOHNSON electronically signed operative reports falsely stating that
he had performed four atherectomies on T.D. and caused corresponding fraudulent

claims to Medicare, as follows:

DATE OF CLAIM CPT HCBP AMOUNT
SERVICE DATE CODE(S) | PROGRAM | CLAIMED
04/17/2019 | 04/24/2019 37225 Medicare $21,752.00
04/25/2019 | 05/02/2019 37229 Medicare $21,478.00
37233 $2,944.00
05/30/2019 | 06/03/2019 37225 Medicare $21,752.00
06/13/2019 | 06/14/2019 37229 Medicare $21,478.00
37233 $2,944.00

DEGRAFT-JOHNSON added SUR appointments to the EMR calendar for the
April 25 and June 13 claims after the fact. AUSTIN then modified those
appointments to reflect a Visit Status of “Checked Out.” DEGRAFT-JOHNSON
was physically located in the Republic of Ghana on April 25, 2019. Medicare paid

DEGRAFT-JOHNSON approximately $39,502.96 for these four fraudulent claims

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DATE OF CLAIM CPT HCBP AMOUNT
SERVICE DATE CODE(S) | PROGRAM | CLAIMED
05/30/2018 | 05/31/2018 37225 Medicare $21,752.00
06/15/2018 | 06/25/2018 37229 Medicare $21,478.00

07/09/2018 |_07/10/2018 37225 Medicare $21,752.00
07/12/2018 | 07/17/2018 37229 Medicare $21,478.00

DEGRAFT-JOHNSON added SUR appointments to the EMR calendar for the June
15 and July 12 claims after the fact. Each of these four claims included R.J.L.’s
name, date of birth, and Medicare beneficiary number, which is based on
beneficiary’s Social Security number. Medicare would not have paid the claims
without inclusion of those means of identification in support of the claims. Medicare
paid DEGRAFT-JOHNSON approximately $33,191.54 for these fraudulent
claims. For the July 12, 2018, date of service, DEGRAFT-JOHNSON, caused
claims for a total of 10 phantom atherectomy procedures, including R.J.L. and 9
other patients.
54. The patient B.M.W. is a 61 year old female and CHP beneficiary.

a. According to B.M.W., she went to HVINF five times. She had
procedures twice. After these procedures, DEGRAFT-JOHNSON told her that she
did not have any blockages in her legs.

b. A review of EMR and CHP records for B.M.W. shows that
DEGRAFT-JOHNSON electronically signed operative reports falsely stating that
he had performed four atherectomies on B.M.W. and caused corresponding

fraudulent claims to CHP, as follows:

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that claim. CHP paid DEGRAFT-JOHNSON a total of $74,232.22 for a total of
eight atherectomy claims related to H.R.

d. The patient P.M.R. is a 74 year old female and CHP beneficiary.
P.M.R. had an established patient visit with a medical assistant at HVINF on January
15, 2019, while DEGRAFT-JOHNSON was abroad. On January 24, 2019,
DEGRAFT-JOHNSON added a SUR appointment to the January 15, 2019, EMR
calendar for P.M.R. and electronically signed an operative report falsely stating that
he had performed an atherectomy on P.M.R. on January 15, 2019. AUSTIN then
modified the SUR appointment to show a Visit Status of “Checked Out.”
DEGRAFT-JOHNSON caused Company A to bill CHP $21,478.00 for this
procedure under CPT Code 37229 and $2,944 for CPT code 37233. CHP paid
HVINF $14,252.69 for that claim. CHP paid DEGRAFT-JOHNSON a total of
$46,537.14 for a total of four atherectomy claims related to P.M.R. Images available
for dates of service January 8 and January 28, 2019, show P.M.R.’s condition as
normal.

e. The patient D.H. is a 71 year old female and Medicare
beneficiary. D.H. had an established patient visit with a medical assistant at HVINF
on January 15, 2019, while DEGRAFT-JOHNSON was abroad. On January 24,
2019, DEGRAFT-JOHNSON added a SUR appointment to the January 15 EMR

calendar for D.H. and electronically signed an operative report falsely stating that

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12/06/2017 12/11/2017 37229 BCBS $21,478.00
11/20/2019 11/26/2019 37225 BCBS $21,752.00
12/02/2019 12/03/2019 37229 BCBS $21,478.00

37233 $2,944.00
12/04/2019 12/09/2019 37225 BCBS $21,752.00
12/09/2019 12/10/2019 37229 BCBS $21,478.00

37233 $2,944.00

BCBS paid DEGRAFT-JOHNSON $107,808 in reimbursements for these
fraudulent claims. Diagnostic images available for the November 6 and November
29, 2017, dates of service show S.R.’s condition as normal.

49. The patients T.M.L and D.F.L. are married. T.F.L. is a 58 year old
female. D.F.L. is a 60 year old male. They are BCBS beneficiaries.

a. According to T.M.L and D.F.L., they were both referred to
DEGRAFT-JOHNSON by their primary care physician. They both had painful
varicose veins in their legs. They had consultations with DEGRAFT-JOHNSON
on the same day. DEGRAFT-JOHNSON told them that there were five steps for a
good cardiac health workup. Those include ultrasounds, echocardiograms, a stress
test, ultrasound of the carotids and checking blood flow in the legs. After checking
the blood flow in their legs DEGRAFT-JOHNSON told T.M.L. and D.F.L. that
they eachneeded an angiogram to check for blockages. The first time they each went
in for an angiogram on one leg. DEGRAFT-JOHNSON performed the procedures.
They were given some pain medications and the procedure took about 20-30
minutes. They returned soon for a follow-up visit. DEGRAFT-JOHNSON told

D.F.L. that he had bad blood flow but no blockages. DEGRAFT-JOHNSON told

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DEGRAFT-JOHNSON again stated, falsely, that “[flor every patient we encounter,
we utilize . . . [t]he Abbot[t] I-Stat system to obtain objective quantification such as
serum creatinine levels and GFR which is the best metric.”

22. Beginning in December 2015, DEGRAFT-JOHNSON utilized the
EMR system. The EMR includes an electronic calendar with patient appointments
classified as established patient visits (“ESTPT”) and surgeries (“SUR”). The
appointments are color-coded on the calendar. The color of the appointment relates
to the “Visit Status.” The color purple indicates that an appointment is “pending.”
HVINF staff would change the color code to red when the patient actually arrived
for “Checked In,” and then change it to green after the patient left to indicate
“Checked Out.” For appointments that actually took place, there is a record of
HVINF staff modifying the appointment several times on the date of service to check
patients in and out. To generate operative reports in the EMR for Steps 2 and 4 of
the scheme, DEGRAFT-JOHNSON had to generate another appointment for the
patient on the EMR. The following is one example, reflecting, in purple, 9 phantom

surgery claims on a single day:

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related to T.D. Images available from the April 17 and May 30, 2019, dates of service
show T.D.’s condition as normal.
64. DEGRAFT-JOHNSON traveled to the Republic of Ghana on April

19, 2019. He returned to the United States on April 27, 2019.

a. The patient C.G. is a 65 year old male and BCBS beneficiary.
C.G. had an established patient visit with a medical assistant at HVINF on April 25,
2019, while DEGRAFT-JOHNSON was abroad. On May 1, 2019, DEGRAFT-
JOHNSON added a SUR appointment to the April 25 EMR calendar for C.G. and
electronically signed an operative report falsely stating that he had performed an
atherectomy on C.G. on April 25, 2019. AUSTIN then modified the SUR
appointment to show a Visit Status of “Checked Out.” DEGRAFT-JOHNSON
caused Company A to bill Medicare $21,478.00 for this procedure under CPT Code
37229 and $5,888.00 for CPT code 37233. Medicare paid HVINF $10,404.77 for
that claim. Medicare paid DEGRAFT-JOHNSON a total of $39,502.96 for a total
of four atherectomy claims related to C.G. Images available from the April 3 and
April 17, 2019, dates of service show C.G.’s condition as normal.

b. The patient A.H. is a 38 year old female and Medicare
beneficiary. A.H. had an established patient visit with a medical assistant at HVINF
on April 25, 2019, while DEGRAFT-JOHNSON was abroad. On May 1, 2019,

DEGRAFT-JOHNSON added a SUR appointment to the April 25 EMR calendar

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66. DEGRAFT-JOHNSON traveled to the Republic of Ghana on June 7,
2019. He returned to the United States (New York, New York) on June 10, 2019.
On June 12, 2019, DEGRAFT-JOHNSON traveled from New York to Tallahassee,
Florida. The patient S.G. is a 42 year old female and BCBS beneficiary. S.G. had an
established patient visit with a medical assistant at HVINF on June 10, 2019, while
DEGRAFT-JOHNSON was abroad. On June 12, 2019, DEGRAFT-JOHNSON
added a SUR appointment to the June 10, 2019, EMR calendar for S.G. and
electronically signed an operative report falsely stating that he had performed an
atherectomy on S.G. on June 10, 2019. AUSTIN then modified the SUR
appointment to show a Visit Status of “Checked Out.” DEGRAFT-JOHNSON
caused Company A to bill BCBS $21,478.00 for this procedure under CPT Code
37229 and $2,944.00 under CPT Code 37233. BCBS paid HVINF $14,822.96 for
that claim. BCBS paid DEGRAFT-JOHNSON a total of $80,103.43 for six other
atherectomy claims related to S.G.

67. _DEGRAFT-JOHNSON traveled to the United Kingdom on June 20,
2019. He returned to the United States on June 23, 2019. The patient J.M. is a 56
year old male and BCBS beneficiary. On June 21, 2019, J.M. had an established
patient visit with a medical assistant at HVINF while DEGRAFT-JOHNSON was
abroad. On June 24, 2019, DEGRAFT-JOHNSON added a SUR appointment to

the June 21 EMR calendar for J.M. and electronically signed an operative report

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HVINF, Employee 2 had access to the EMR for a period of time. Employee 2 noticed
that patients had surgeries documented in the EMR which Employee 2 knew had not
occurred. Employee 2 mentioned this to AUSTIN. AUSTIN falsely stated to
Employee 2 that this was a mistake. After seeing more patients’ surgeries
documented which had not taken place, Employee 2 raised the issue with AUSTIN
again. AUSTIN told Employee 2 that Employee 2 did not understand how to bill
and it had to be done that way. AUSTIN described the practice as “bundling.”
Sometime after this conversation, on May 18, 2017, AUSTIN terminated Employee
2’s access to the EMR. AUSTIN falsely stated that Employee 2’s access to the EMR
was an unnecessary expense, when in truth there was no difference in costs
associated with Employee 2 having access to the EMR. Employee 2 submitted
numerous anonymous complaints that HVINF was engaged in health care fraud.
27. Employee 5 was the assistant office manager at HVINF from January
2017 until February 13, 2020. In August of 2017, Employee 5 noticed surgeries on
the EMR calendar which Employee 5 knew did not take place. Employee 5 brought
this to the attention of AUSTIN and then later to DEGRAFT-JOHNSON. About a
month later, Employee 5 observed that the calendar had not been corrected.
Employee 5 asked AUSTIN what was going on. AUSTIN told Employee 5 that

Employee 5 did not understand billing or “how things worked.”

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