United States v. Weiss

914 F.2d 1514, 1990 U.S. App. LEXIS 16643
CourtCourt of Appeals for the Second Circuit
DecidedSeptember 19, 1990
DocketNos. 781, 782, Docket 89-1434, 89-1444
StatusPublished
Cited by17 cases

This text of 914 F.2d 1514 (United States v. Weiss) is published on Counsel Stack Legal Research, covering Court of Appeals for the Second Circuit primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
United States v. Weiss, 914 F.2d 1514, 1990 U.S. App. LEXIS 16643 (2d Cir. 1990).

Opinion

FRIEDMAN, Circuit Judge:

In this appeal the appellants Gleicher and Patient Medical Systems Corp., a/k/a “Integrated Generics, Inc.” (“Patient Medical”), challenge on various grounds their criminal convictions after a jury trial in the United States District Court for the Eastern District of New York of mail fraud, mail fraud conspiracy, and making false representations of material facts on Medicare and Medicaid claims. The third convicted defendant, Weiss, had not been sentenced at the time this appeal was argued, and therefore did not join in the appeal.

The indictment, filed in July 1988, charged the three defendants named above and Health-Med, Inc. (“Health-Med”), a predecessor corporation of Patient Medical, with a conspiracy from February 1983 to December 1986, to defraud and to obtain money from the Health and Human Services Administration by means of false and fraudulent pretenses and representations. The indictment alleged that “[t]he object of the conspiracy was” “to obtain federal funds by and through the fraudulent submission of Medicare Claim Forms to Ohio, Illinois and New Jersey Medicare carriers for services with a ‘point of sale’ in New York, in order to receive the higher rate of Medicare reimbursement paid by these out-of-state carriers,” and that pursuant to the conspiracy the defendants “submitted[] Medicare Claim Forms to the Ohio, Illinois, and New Jersey Medicare carriers, knowing that these Medicare Claim Forms should have been submitted to New York Medicare carriers.”

Following the jury convictions, the district court sentenced Gleicher to three years’ imprisonment, followed by five years’ probation, and fines and a court assessment totaling $126,900. The court sentenced Patient Medical to fines, prosecution costs, and court assessments totaling $173,650.

I

A. The Statutory and Regulatory Scheme for the Payment of Medicare Claims.

Under Part B of Medicare, providers of “medical and other health services,” which include providers of “durable medical equipment ... used in the patient’s home ... whether furnished on a rental basis or purchased,” 42 U.S.C. § 1395x(s)(6), are en[1516]*1516titled to reimbursement for the reasonable cost of providing such services. 42 U.S.C. § 1395k(a)(2)(B). One example of such “durable medical equipment,” for which reimbursement is available, is the “rental or purchase of a medically necessary seat lift when prescribed by a physician for a pa-tient_” Medicare Carriers Manual, § 60-8.

Within the Department of Health and Human Services (the “Department”) the Health Care Financing Administration (the “Administration”) is responsible for the administration of Part B of Medicare. Reorganization Order effective March 8, 1977. The Administration has promulgated the Medicare Carriers Manual (the “Manual”), which is the official explanation of the Medicare statute and the regulations.

Pursuant to statutory authority, 42 U.S.C. § 1395u(a), the Secretary has entered into contracts with entities throughout the country to process and pay Medicare claims. There are 47 such entities, known as carriers, each of which is responsible for paying claims in a specified geographic area.

Each individual carrier sets the amount it will pay for a particular service. As a result, the amounts the different carriers will pay for the same service may vary from carrier to carrier. The Manual explains the basis upon which a provider of services is to determine to which carrier it should submit a claim:

Jurisdiction of payment requests for services of a supplier ... with branch offices or sales/rental outlets in more than one carrier’s jurisdiction lies with the carrier for the location where the service is furnished to the beneficiary whether or not the supplier uses a central billing office. (This means the site where the company met with the beneficiary or received the beneficiary’s call.) All claims for the services of suppliers from branch officers or sales/rental outlets outside the carrier’s service area must be transferred to the appropriate carrier for processing.

Manual, § 3102.B, at 3-63.2 — 3-64.1. The Manual provides “EXAMPLES OF MUL-TI-CARRIER JURISDICTION,” which explain in detail how this rule works. Id. at 3-64.1 — 3-64.3.

The “location where the service is furnished to the beneficiary,” i.e., the “site where the company met with the beneficiary or received the beneficiary’s call,” and which determines the carrier to which the claim should be submitted, is known in the Medicare field as the “point of sale.”

In addition to being published in the Manual, the rules governing the carrier to which a claim should be submitted are also from time to time published by the carriers themselves, in publications they send to providers. See, e.g., Medicare Newsletter for Durable Medical Equipment Suppliers, at 8 (Nationwide Mut. Ins. Co., Ohio July 1981).

One of the carriers to whom Patient Medical submitted Medicare claims was Nationwide Insurance Company, the Medicare carrier for Ohio (“Ohio Nationwide”). In the regular course of business, Ohio Nationwide distributes bulletins to all durable medical equipment providers that are registered with it, including Patient Medical. One bulletin, dated July 1981, explained:

Processing jurisdiction for services of a supplier with branch offices or sales/rental outlets in more than one carrier’s jurisdiction lies with the carrier for the location where the service is furnished to the beneficiary whether or not the supplier uses a central billing office — this means the site where the company met with the beneficiary or received the beneficiary’s call. All claims for the services of suppliers from branch offices or sales/rental outlets outside the carrier’s service area must be submitted to the appropriate carrier for processing.

Id. at 8. “[Tjhat particular document [is] sent to all providers that bill [the] carrier” and “from time to time over the years ... similar documents [are sent] to the providers explaining how to bill the carrier.” Moreover, Ohio Nationwide “send[s] out current and past newsletters that are pertinent to that particular practice.” At the time Health-Med first joined the Medicare program, Ohio Nationwide sent it a similar [1517]*1517bulletin stating that “[t]he revised policy [of the Administration] stipulates that, effective with dates of service of July 1, 1977, jurisdiction is based on the point of sale, regardless of where the billing is being done,” Medicare Bulletin (Nationwide Mut. Ins. Co. undated) (emphasis in original). A similar notice was included in a December 1985 Blue Cross/Blue Shield of Illinois newsletter.

Form 1500 is the official form, prepared by the Administration and approved by the Office of Management and Budget, on which a provider submits a claim for reimbursement to a carrier. Each carrier has its own version of the Medicare form.

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Bluebook (online)
914 F.2d 1514, 1990 U.S. App. LEXIS 16643, Counsel Stack Legal Research, https://law.counselstack.com/opinion/united-states-v-weiss-ca2-1990.