Prosecutors Say Insurer Was Billed for Brain Surgery That Never Occurred

It may have been the nine brain operations that Stanley Canella claimed that he, his wife and their two sons had from April 2003 to September 2006 that piqued the interest of federal investigators.

Then again, it may have been that all four members of the family received insurance reimbursements for the same surgery on the same brain.

Federal prosecutors did not discuss yesterday how they came to charge Mr. Canella and three other people with bilking an insurance company out of about 0,000 with falsified post-operative reports. They did say that although the four defendants had billed the company for 20 brain operations, none had been performed.

Mr. Canella, 36, remained at large yesterday. He faces charges of mail and health-care fraud, officials said. His three co-defendants — Charles Pritchett, 39, of Mount Vernon, N.Y.; Dorothy L. Smith, 42, of Manhattan; and Michael Biscotti, 37, of Staten Island — were in custody and likely to be arraigned next week. Officials declined to describe the relationships of the four defendants. Because they had not yet been arraigned, it was unclear whether they had hired lawyers.

The scheme began on April 28, 2003, prosecutors say, when Mr. Pritchett, a billing technician at a medical billing company in Hawthorne, N.Y, cracked into his company’s computers. He gained access to the insurance claims and post-operative reports for two patients who had visited a Manhattan neurosurgeon, prosecutors say.

Using the forms as a template, Mr. Pritchett then simply plugged in the names, ages, addresses and similar information for the Canellas, the Smiths, and Mr. Biscotti and his wife, according to a federal indictment issued yesterday. The forms were sent to Group Health Inc., a Manhattan insurance carrier, prosecutors said.

From April 2003 to September 2006, Mr. Canella received 2,268 in reimbursements from Group Health, the indictment says. This was for nine supposed operations for the various members of his family —one of which Mr. Canella was accused of billing for three separate times, prosecutors say.

Ms. Smith also billed — and received money — for nine brain operations for herself and her family, prosecutors say. She is charged with having defrauded Group Health of 1,397.

Mr. Biscotti got a lesser sum, ,041, for operations that he and wife had supposedly undergone, prosecutors say. Mr. Pritchett faces a maximum penalty of 90 years in prison if convicted. The others face maximum sentences of 30 years.

Ilene Margolin, a spokeswoman for Group Health, said it was the company’s own internal investigators who first noticed something awry in the defendants’ claims. The company then turned its findings over to the government.

“We’re glad the United States attorney’s office was able to make a case,” she said.

More Topics:
Medical Billing Online - Doctors Online Billing
Medical Billing Services for Healthcare Providers. Our Online Billing Systems are Secure, ... Doctors Online Medical Billing. Moving the Boundaries in Business ...