San Diego, California Chiropractor Sentenced to Three Years in Jail for Multi-million Greenback Staff’ Compensation, Medicare, and TRICARE Schemes, DOJ Studies

April 14, 2021 – SAN DIEGO – Joserodel Zavala Candelario, who lives in Irvine, was sentenced to 36 months in prison in federal court Monday for participating in two major health benefits Scam programs and for disguising any income he received from these multi-million dollar programs.

According to court records, Candelario was a chiropractor who was approved by the California State Board of Chiropractic Examiners. He owned Candelario Chiropractic, a professional corporation, and RISE Medical Center, a professional corporation, dba RISE Wellness Center (“RISE Wellness”), which operated in several locations in the southern District of California, including 5030 Bonita Road . Suite B at Bonita and 3231 Waring Road, Suite N at Oceanside.

On January 21, 2020, the defendant pleaded guilty to replacing three pieces of information and charged with conspiracy in violation of 18 USC Section 371, conspiracy to commit healthcare fraud in violation of 18 USC Section 1349, and false tax return declaration in violation of 26 USC § 7206 (1). Separately, the defendant has been indicted and pleaded guilty in San Diego Supreme Court Case SCD281328 of concealing an insurance claim incident in violation of California Penal Code 550 (b) (3).

The government’s verdict reflects that, between roughly 2012 and July 2016, Candelario ran a program to defraud Medicare and TRICARE out of millions of dollars by using physical therapy codes to bill alleged physical therapy services for patients who Have been performed by unlicensed individuals to offer physical therapy, including chiropractors, massage therapists, physical therapists, and acupuncturists. As a result, patients who believed they were receiving medical treatment received substandard care instead, allowing Candelario to bill Medicare and TRICARE.

Candelario and his co-conspirators told patients that RISE Wellness was offering an “integrated” approach to wellness in order to convince patients to accept physical therapy, acupuncture, chiropractic and diagnostic services at RISE Wellness in order to fraudulently bill uncovered services to pose from unauthorized persons and collect as much money as possible from health programs.

Candelario specifically targeted TRICARE beneficiaries as patients, although TRICARE was known to fail to cover many of the services provided by providers at RISE Wellness. The main page of the RISE Wellness website has made this objective clear. It showed a photo of a person in military uniform saluting with the message “Supporting spinal health”. . . You only have one back. Take Great Care With Supportive Chiropractic “although TRICARE, the DoD Uniformed Service Personnel Health Program, did not cover chiropractic.

As soon as the patients walked in the door, the defendant urged his staff to run diagnostic tests on any patient, regardless of medical need, in order to increase billing and pay, and he urged staff to reduce the quotas on the minimum number of diagnostic tests and recommendations for performing long-life medical devices or DME, massages and other services, regardless of whether certain patients required the items and services. He also set quotas for the minimum number of patients with certain types of insurance coverage with RISE Wellness, such as: B. “60 Tricare patients per day”, regardless of whether these patients required treatment.

For example, on June 6, 2014, Candelario instructed a worker: “You have to do 5 axonii [diagnostic tests] one day no matter what happens now. “The following month, July 7, 2014, Candelario wrote,” OK, team, you are getting two new diagnostic testers this month. I need 20 patients to be tested on everyone this month no matter what [sic]. ”

The defendant knew that TRICARE and Medicare had not paid for chiropractic, acupuncture, massage and other services and characterized those services as physical therapy in bills filed with TRICARE and Medicare.

To increase billing and payment, the defendant urged planners to cram up to 50 patients per day for each provider. He complained when staff failed to achieve this goal and noted certain “problems at the front desk” on June 11, 2015, including: “No.[one] has urged all patients to fill blank spaces in provider plans or grab patients in lobbies for inclusion in provider plans. “

Candelario fired or marginalized employees who disagreed with its efforts to prescribe, recommend, provide, or bill in a manner primarily intended to increase billing and payment to RISE Wellness, and contrary to that Medicare and Tricare rules and the medical needs of patients. On October 1, 2015, Candelario instructed chiropractors not to treat patients unless they had previously prescribed X-rays and three other diagnostic tests, as well as DME. On October 19, 2015, Candelario finally informed a co-conspirator: “I find it very difficult what needs we have [to retain the PA] go forward. “About a week later, the PA was fired.

If a patient did not show up for an appointment, Candelario instructed staff to bill the service program for the visit even though no visit had been made and no service had been provided. For example, on March 9, 2015, Candelario wrote about late reimbursements: “The only solution is to bill the missed appointments as I asked the system to do.”

It was part of the program that the co-conspirators were required to submit and arrange false and fraudulent invoices of at least $ 7,260,327.20 with TRICARE and Medicare using the means and methods described above and other methods. Of these fraudulent invoices, TRICARE paid a total of $ 3,450,596.43 and Medicare paid $ 37,843.04.

Additionally, between March 2012 and November 2015, Candelario conducted an illegal referral scheme that would receive new patients with Workers’ Compensation (“WC”) for RISE Wellness. In exchange for new patients, Candelario agreed to maintain a quota on the “value” of ancillary services and DME that he should prescribe for each patient with a “value” of approximately $ 30 to $ 50 sent to him by co-conspirators by MRI – Transfer – set by these conspirators. As part of the program, Candelario, who could act as the primary toilet provider, dictated the same treatment plan for all toilet patients, regardless of their individual medical needs, so he could fraudulently bill toilet insurers. The defendant admitted that he had violated his duty to honestly serve his patients. As a result of the program, he received approximately 529 new toilet patients and billed insurers for approximately $ 6,605,364 for services provided to these patients. Of those billed amounts, he was paid $ 771,000 by toilet insurers

Candelario not only spruced up tax-funded government programs out of millions of dollars, but failed to pay his fair share of taxes on the funds he fraudulently received, resulting in tax losses of $ 505,000 for the 2013 tax year alone.

Judge Bashant attributed the defendant’s rehabilitation efforts to improving his circumstances since his conviction. Statements in criminal papers and in court reflect that the defendant taught as an additional instructor at West Coast University, Canyon College, Santa Ana College, Orange Coast College and National University on subjects such as human anatomy, human physiology, biology . Medical ethics and medical billing. To make matters worse, Candelario “put profits above the medical needs of the patients”, which warranted punishment.

“With so many health systems and workers overwhelmed by the pandemic, we cannot afford the financial and physical costs of fraud,” noted acting US attorney Randy Grossman. “Doctors are especially guilty of violating the sacred trust they should place in their patients. We work hard every day to protect patients, taxpayers, and interest payers who are exploited by members of the medical community who prefer purchasing power to principle. “Mr. Grossman commended the work of AUSAs Valerie H. Chu and Michelle Wasserman, forensic auditors Robbin Ganicliffe and Attorney Joan Carter, and case agents from the FBI, DCIS and IRS-CI.

“With this verdict, the accused has now been brought to justice for years of lies and deception in the fraudulent activity of our health system,” said the FBI special agent in charge, Suzanne Turner. “Let this phrase serve as a warning to those who are purposely trying to fill their pockets with scam programs rather than providing the honest service and care that people deserve.”

The defendant requested a delay in the self-handover date until the submission of grades for the current school year he is teaching. The defendant is said to surrender himself on or before July 14th at 12:00 noon. A hearing on forfeiture and refund will be held on May 19 at 2:00 p.m. The United States is demanding a refund of $ 3,450,596.43 to TRICARE, $ 37,843.04 to Medicare, and a personal monetary judgment of $ 1,300,899.63.

DEFENDANT Case number 18CR3057-BAS, 18CR3058-BAS

Joserodel Zavala Candelario Age: 48 years old Irvine, CA.

SUMMARY OF FEES

Conspiracy – Title 18, USC, Section 371

Maximum sentence: 5 years imprisonment and a fine of $ 250,000

Conspiracy to Commit Health Care Fraud – Title 18, USC, Section 1349

Maximum sentence: Ten years in prison and a fine of $ 250,000

Subscribing to a False Tax Return – 26 USC §7203 (1)

Maximum sentence: three years in prison and a fine of $ 100,000

AGENCIES

Federal Office for Investigations

Defense Criminal Police

Internal Revenue Service – criminal investigation department

California Department of Insurance
Source: DOJ