4 guilty in $5.2M Medicare fraud scheme in Houston
Recent Cases
Four people have been convicted in Houston of conspiring to defraud the Medicare program out of $5.2 million over a three-year period.
A Justice Department statement identifies the four convicted Wednesday as 46-year-old Ezinne Ubani, 45-year-old Caroline Njoku and 47-year-old Terrie Porter, all of Houston, and 55-year-old Mary Ellis of Missouri City.
The federal jury in Houston acquitted 62-year-old Estella Joseph of Houston, all after a 15-day trial before U.S. District Judge Nancy Atlas.
Sentencing is scheduled for July 20-21. Ubani and Ellis could receive up to 20 years in prison, Njoku could get up to 15 years in prison, while Porter could get up to 10 years in prison.
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Workers’ Compensation Subrogation of Administrative Fees and Costs
When a worker covered by workers’ compensation makes a claim against a third party, the workers’ compensation insurance retains the right to subrogate against any recovery from that third party for all benefits paid to or on behalf of a claimant injured at work. When subrogating for more than basic medical and indemnity benefits, the Texas workers’ compensation subrogation statute provides that “the net amount recovered by a claimant in a third‑party action shall be used to reimburse the carrier for benefits, including medical benefits that have been paid for the compensable injury.” TX Labor Code § 417.002.
In fact, all 50 states provide for similar subrogation. However, none of them precisely outlines which payments or costs paid by a compensation carrier constitute “compensation” and can be recovered. The result is industry-wide confusion and an ongoing debate and argument with claimants’ attorneys over what can and can’t be included in a carrier’s lien for recovery purposes.
In addition to medical expenses, death benefits, funeral costs and/or indemnity benefits for lost wages and loss of earning capacity resulting from a compensable injury, workers’ compensation insurance carriers also expend considerable dollars for case management costs, medical bill audit fees, rehabilitation benefits, nurse case worker fees, and other similar fees. They also incur other expenses in conjunction with the handling and adjusting of workers’ compensation claims. Workers’ compensation carriers typically assert, of course, that, they are entitled to reimbursement for such expenditures when it recovers its workers’ compensation lien. Injured workers and their attorneys disagree.