An Integrated Approach to Fraud

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High Angle View Of A Person With Fractured Hand Filling Health Insurance Form

A California Chiropractor and owner of R.I.S.E Medical Center (RISE Wellness) told patients that his company, which operated in Bonita and Oceanside, offered an “integrated” approach to wellness, which included a host of services such as physical therapy, acupuncture, chiropractic, and diagnostic services. What he should have explained was that he offered an integrated approach to fraudulently billing for non-covered services provided by unauthorized individuals. (That’s so he could collect as much money as possible from a variety of health insurance programs. About $7.2 million to be exact.)

Joserodel Zavala Candelario of Irvine was a licensed chiropractor, who attempted to defraud Medicare and TRICARE out of millions of dollars. He did this by using physical therapy codes to bill for services rendered by chiropractors, massage therapists, physical therapy aides and an acupuncturist who were not licensed to provide physical therapy services. (Patients thought they were being treated by qualified individuals, but they were receiving substandard care.)

Candelario liked quotas. He pushed his staff to conduct diagnostic tests on every patient whether they needed it or not. The chiropractor set quotas for the minimum number of diagnostic tests and recommendations for durable medical equipment (DME), massages, and other services. Despite knowing that TRICARE doesn’t cover most of the services provided at RISE Wellness, Candelario targeted TRICARE beneficiaries, even going as far as to put photos of military personnel on his company’s website. (Employees were supposed to treat 60 TRICARE beneficiaries per day.)

Other tactics he used included requiring schedulers to cram in 50 patients per provider per day. (If you factor in an eight-hour day, that gives each provider just under 10 minutes to treat each patient. And that doesn’t include a lunch or bathroom break.) Candelario suggested that staff actually “grab patients in lobbies to put into provider schedules.”(That’s a bit scary.) When his staff disagreed with his aggressive goals and billing practices, they were fired.

Candelario branched out to workers compensation fraud to earn even more money he didn’t deserve. For nearly four years, he carried out a cross-referral scheme where he would receive new workers’ compensation patients at RISE Wellness. For every individual that was referred to his company, he agreed to prescribe an agreed upon amount of DME. He scammed 529 workers’ compensation patients and submitted more than $6.6 million in bills. (He was paid $771,000 by workers’ compensation insurers.)

But, that’s not all folks. In addition to scamming healthcare and workers compensation programs out of millions of dollars, he also committed tax fraud by not paying $505,000 in taxes in 2013. Candelario pleaded guilty to healthcare fraud, tax fraud, and to concealing an event affecting an insurance claim. He was sentenced to three years in federal prison.

The judge in the case commended Candelario’s efforts to rehabilitate following his conviction. He is teaching as an adjunct instructor at five colleges and universities covering topics such as human anatomy, human physiology, biology, Medical Ethics and Medical Billing. (Hopefully, he didn’t give a tutorial to any of his students on how to commit fraud.) He agreed to self-surrender once grades have been submitted for the current school term he is teaching. Then he’ll report to serve his sentence. (Sounds like he’ll be learning how to integrate into the federal prison system very soon.)

Today’s Fraud of the Day comes from a Department of Justice press release, “San Diego Chiropractor Sentenced to Three Years in Prison for Multi-million Dollar Workers’ Compensation, Medicare, and TRICARE Schemes,” dated April 13, 2021.

SAN DIEGO – Irvine resident Joserodel Zavala Candelario was sentenced in federal court yesterday to 36 months in federal custody for his participation in two huge health care fraud schemes, and for concealing income he received from those multi-million dollar schemes.

According to court documents, Candelario was a chiropractor licensed by the State of California Board of Chiropractic Examiners. He was the owner of Candelario Chiropractic, a Professional Corporation, and R.I.S.E. Medical Center, a Professional Corporation, dba R.I.S.E. Wellness Center (“RISE Wellness”), which operated at multiple locations in the Southern District of California, including at 5030 Bonita Road, Suite B, in Bonita and at 3231 Waring Road, Suite N, in Oceanside.

 

 

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Larry Benson, Senior Director of Strategic Alliances, LexisNexis Risk Solutions - Government

Larry Benson is responsible for developing strategic partnerships and solutions for the government vertical. His expertise focuses on how government programs are defrauded by criminal groups, and the approaches necessary to prevent them from succeeding.

Mr. Benson has 30 years of experience in sales and business development. Before joining LexisNexis® Risk Solutions, he spent 12 years founding and managing two software technology startups. During the 1990s he spent 10 years as a Regional Director helping to grow a New England-based technology company from 300 employees to 7,000. He started his career with Martin Marietta Aerospace working on laser guided weapons and day/night vision systems.

A sought-after speaker and accomplished writer, Mr. Benson is the principal author of “Fraud of the Day,” a website dedicated to educating government officials about how criminals are defrauding government programs. He has co-authored WTF? Where’s the Fraud? How to Unmask and Stop Identity Fraud’s Drain on Our Government, and Data Personified, How Fraud is Changing the Meaning of Identity.

Benson holds a Bachelor of Science in Physics from Albright College, and earned two graduate degrees – a Master of Business Administration from Florida Institute of Technology, and a Master of Science in Engineering from Lehigh University.