Health care fraud schemes exposed and more

Leader of $42 million elder fraud scheme pleads guilty

The leader of a money-laundering cell in San Diego pleaded guilty in federal court to helping facilitate a $42 million international elder fraud scheme. The cell leader, Victor Marion, admitted to mail and wire fraud conspiracy and money laundering along with 21 alleged coconspirators.

The San Diego scheme was part of a long‑running call-center operation based in Dubai and India that targeted older adults across the U.S. Marion and his coconspirators lured victims with fake technical support pop‑up ads and posed as representatives of companies such as Microsoft or McAfee.

After charging victims a fee for fake tech-support services, scammers then used remote desktop tools to make it look as if they’d refunded thousands of dollars to victims. Victims were then pressured to mail or wire the fake “overpayments,” to U.S.-based money transmitters, including the laundering outfit led by Marion.

Health care fraud schemes targeted in U.S.

Two recent settlements involving medical providers in the U.S. highlight the government’s efforts to stamp out fraud in its Medicare and Medicaid programs. Medicare is a federal health insurance program for older adults and younger people with disabilities. Medicaid provides health coverage for low-income individuals, families, children and people with disabilities. The settlements also demonstrate the continuing importance of whistleblower actions in uncovering fraud and recovering taxpayer funds.

Five Kaiser Permanente affiliates agreed to pay $556 million to resolve allegations that they violated the False Claims Act by submitting invalid diagnosis codes for Medicare Advantage enrollees to obtain inflated payments. Medicare Advantage is a health plan offered by private insurers in the U.S. 

Prosecutors say Kaiser pressured physicians in California and Colorado to add unsupported or unrelated diagnoses — sometimes months after patient visits — to boost federal reimbursements under the Medicare Advantage risk‑adjustment model. The scheme, which allegedly operated from 2009 to 2018, involved mining patients’ medical histories to identify additional diagnoses that could increase payments.

The case, filed by the government in 2021, resulted in one of the largest Medicare Advantage fraud settlements to date. The complaint incorporated allegations from whistleblowers, including two former Kaiser employees. Kaiser denied wrongdoing.

In another settlement, five Florida-based ophthalmology practices agreed to pay nearly $6 million to resolve allegations that they submitted fraudulent claims to Medicare and Medicaid for medically unnecessary transcranial Doppler ultrasounds.

According to the U.S. Department of Justice (DOJ), the practices knowingly billed the government programs for these tests as part of an illicit kickback arrangement with a third-party testing company. The testing company then identified patients as having serious conditions that would justify reimbursement even though those diagnoses weren’t supported by the patients’ medical records or test results. The scheme allegedly operated from 2018 to 2022 and involved thousands of unnecessary ultrasounds.

The DOJ emphasized that kickbacks and false billing undermine the integrity of federally funded health care programs, drive up costs for taxpayers and compromise medical decision‑making. All five practices have agreed to cooperate with ongoing investigations.

Global authorities unmask money laundering schemes

Governments and financial regulators are intensifying efforts to combat money laundering, as demonstrated by two recent enforcement actions. The U.S. Department of Justice (DOJ) prosecuted a TD Bank insider involved in a transnational money laundering scheme and imposed a record multimillion‑euro penalty on Spain’s CaixaBank for severe anti-money laundering (AML) deficiencies.

Former TD Bank employee Oscar Marcel Nunez‑Flores pleaded guilty to facilitating a large‑scale money laundering network that moved more than $26 million from the U.S. to Colombia. According to the DOJ, Nunez‑Flores accepted bribes to give criminals access to TD Bank’s internal systems and controls.

Court filings show that between 2021 and his arrest in 2023, Nunez‑Flores accepted bribes to open numerous bank accounts tied to shell companies, often creating the accounts without any actual customers present. He issued more than 600 debit cards linked to these accounts, which were later used to make more than 120,000 ATM withdrawals across Colombia. He also mailed debit cards directly to an accomplice in the Latin American country.

In addition, Nunez‑Flores formed shell companies in New Jersey and opened bank accounts for them at TD Bank, collecting payments of roughly $500 to $2,500 (paid either in cash or through digital payment apps) for each account he set up.

Across the Atlantic, Spanish regulators fined CaixaBank 17.6 million euros (with additional fines pushing totals beyond 30 million euros) for gross AML lapses tied to the high‑profile Cepsa Tower real estate transaction in Madrid. The investigation revealed that nearly 100 million euros in illicit funds moved through CaixaBank accounts without adequate scrutiny.

Authorities found that the bank failed to perform mandatory enhanced due diligence and ignored clear red flags. CaixaBank also allowed shell companies and offshore structures connected to politically exposed figures, including former Cepsa chairman Khadem Al Qubaisi, to move large sums undetected. These overlooked risks allowed proceeds of an international money laundering operation to enter the legitimate financial system.

The case represents one of Spain’s largest AML penalties. Regulators stressed that high‑value real estate deals involving opaque ownership structures demand rigorous oversight to prevent financial system abuse.

Crystal Zuzek is associate editor of Fraud Magazine. Contact her at czuzek@acfe.com.