Indictment — No. 2:21-cr-20494 (Dkt. 1, E.D. Mich.)

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An indictment filed July 28, 2021 as ECF No. 1 in Case 2:21-cr-20494 in the U.S. District Court for the Eastern District of Michigan, Southern Division, against Diane Dupree King. It describes the Medicare program and the coverage rules for psychotherapy in Michigan. Counts 1 through 8 charge health care fraud under 18 U.S.C. §§ 1347 and 2, alleging that King submitted or caused false claims to Medicare for psychotherapy services that were not provided or not eligible, with reimbursements deposited to Prestige Behavioral and Prestige Creative. A table lists each count's beneficiary, dates of service and amount billed.

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_ Case 2:21-cr-20494-DML-APP ECF No. 1, PagelD.1 Filed 07/28/21 Page 1 of 13
                                                                                   13

                    UNITED STATES DISTRICT COURT
                    EASTERN DISTRICT OF MICHIGAN
                           SOUTHERN DIVISION

                                          Case:2:21-cr-20494
United States of America,
                                          Judge: Lawson, David M.
                     . oe                 MJ: Patti, Anthony P.
                  Plaintiff,              Filed: 07-28-2021 At 04:34 PM
                                          INDI USA V, SEALED MATTER (DA)
v.

                                                      18 U.S.C. § 2
                  Defendant.                          18 U.S.C. § 982

                              /

                              INDICTMENT

 THE GRAND JURY CHARGES:

                            General Allegations

At all times relevant to this Indictment:

      1.    The Medicare program (“Medicare”) was a federal health care program

providing benefits to persons who were 65 years of age or older or disabled.

Medicare was administered by the Centers for Medicare and Medicaid Services

(“CMS”), a federal agency under the United States Department of Health and

Human Services (“HHS”). Individuals who received benefits under Medicare were

referred to as Medicare “beneficiaries.”

, Case 2:21-cr-20494-DML-APP ECF No. 1, PagelD.2 Filed 07/28/21 Page 2 of 13

2. Medicare was a “health care benefit program,” as defined by Title 18,
United States Code, Section 24(b), and a “Federal health care program,” as defined
by Title 42, United States Code, Section 1320a-7b(f).

3. Medicare included coverage under two primary components, hospital
insurance (“Part A”) and medical insurance (“Part B”). Medicare Part B covered the
costs of medical insurance, including physician, nursing, and other ancillary services
not covered by Part A. The services at issue in this Indictment were covered by Part
B.

4. AdvanceMed (now known as “CoventBridge Group”) was the Zone
Program Integrity Contractor (“ZPIC”), and as such, it was the Medicare contractor
charged with investigating fraud, waste, and abuse, during the relevant time period.

5. Physicians, nurse practitioners, and other health care providers that
provided medical services that were to be reimbursed by Medicare were referred to
as Medicare “providers.” To participate in Medicare, providers were required to
submit applications in which the providers agreed to comply with all Medicare-
related policies and procedures, rules, and regulations issued by CMS and its agents
and contractors, including those governing reimbursement, and furthermore,
certified that they would not knowingly present, or cause to be presented, false and

fraudulent claims.


_ Case 2:21-cr-20494-DML-APP ECF No. 1, PagelD.3 Filed 07/28/21 Page 3 of 13

6. If Medicare approved a provider’s application, Medicare assigned the
provider a Medicare “provider number,” which was used for the processing and
payment of claims.

7. Local Coverage Determinations (“LCDs”), as defined by the Social
Security Act, were decisions made by a Medicare Administrative Contractor
(“MAC”) on whether a particular service or item was reasonable and necessary, and
therefore covered by Medicare within the specific region that the MAC oversaw.
LCDs 34616 and 30489 were titled “Psychiatry and Psychological Services” and
applied to the primary geographical jurisdiction of Michigan. These LCDs specified
that Medicare coverage of psychotherapy did not include teaching grooming skills,
monitoring activities of daily living (“ADL”), recreational therapy (dance, art, play),
or social interaction. It also did not include oversight activities such as house or
financial management. LCD A54829, entitled “Clinical Social Worker Services,”
stated that services furnished as an “incident to” clinical social work (“CSW”)
personal professional services were not covered.

8. Providers were given, and provided with online access to, Medicare
manuals and services bulletins describing proper billing procedures and billing rules
and regulations. Providers could only submit claims to Medicare for services they
rendered, and providers were required to maintain patient records to verify that the

services were provided as described on the claim form. These records were required

_ Case 2:21-cr-20494-DML-APP ECF No. 1, PagelD.4 Filed 07/28/21 Page 4 of 13

to be sufficient to permit Medicare, through its contractors, to review the
appropriateness of Medicare payments made to the health care provider.

9. To receive reimbursement for a covered service from Medicare, a
provider was required to submit a claim, either electronically or using a form (e.g.,
a CMS-1500 form or UB-92), to the Medicare contractor or carrier containing the
required information appropriately identifying the provider, beneficiary, and
services rendered.

10. Medicare only covered services that were both medically necessary and
rendered as billed.

The Businesses

11. Prestige Behavioral Therapy Development Center LLC (“Prestige
Behavioral’’) was a Michigan limited liability company, formed in or around October
2012, and located at 24450 Evergreen Rd., Ste 104, Southfield, Michigan. Prestige
Behavioral was enrolled as a participating provider with Medicare.

12. Prestige Creative Arts Therapy LLC (“Prestige Creative”) was a
Michigan limited liability company, formed in or around December 2009, and
located at 28338 Franklin Rd., Southfield, Michigan. Prestige Creative was enrolled

as a participating provider with Medicare.


_ Case 2:21-cr-20494-DML-APP ECF No. 1, PagelD.5 Filed 07/28/21 Page 5 of 13

The Defendant
13. Defendant DIANE DUPREE KING, a resident of Bloomfield Hills,
Michigan, during the period of the criminal conduct described herein, was the
registered owner for Prestige Behavioral and Prestige Creative and was the sole
signatory on the bank accounts into which Medicare reimbursements to both Prestige

Behavioral and Prestige Creative were deposited.

COUNTS 1 through 8
(18 U.S.C. §§ 1347 and 2 - Health Care Fraud)

14. Paragraphs 1 through 13 of the General Allegations section of this
Indictment are re-alleged and incorporated by reference as though fully set forth
herein.

15. From in or around January 1, 2016, and continuing through present, the
exact dates being unknown to the Grand Jury, in Wayne, Oakland, and Macomb
Counties, in the Eastern District of Michigan, and elsewhere, the defendant, DIANE
DUPREE KING, in connection with the delivery of, and payment for, health care
benefits, items, and services, did knowingly and willfully execute, and attempt to
execute, a scheme and artifice to defraud Medicare, a federal health care benefit
program affecting commerce, as defined in Title 18, United States Code, Section
24(b), and to obtain, by means of materially false and fraudulent pretenses,
representations, and promises, any money and property owned by, or under the

custody or control of, said health care benefit program, in connection with the

5

_ Case 2:21-cr-20494-DML-APP ECF No. 1, PagelD.6 Filed 07/28/21 Page 6 of 13

delivery of, and payment for, health care benefits, items, and services, by submitting
or causing the submission of false and fraudulent claims to Medicare for
psychotherapy services that were not provided and not eligible for reimbursement.

PURPOSE OF SCHEME AND ARTIFICE

16. It was a purpose of the scheme and artifice for DIANE DUPREE KING
to unlawfully enrich herself through the submission of false and fraudulent claims
to Medicare for psychotherapy services that were not provided or were otherwise

not eligible for reimbursement.

THE SCHEME AND ARTIFICE

17. On or about January 29, 2016, DIANE DUPREE KING, on behalf of
Prestige Behavioral, certified to Medicare that she would comply with all Medicare
rules and regulations, including that she would not knowingly present or cause to be
presented a false and fraudulent claim for payment by Medicare. She made the same
certification on behalf of Prestige Behavioral on or about March 29, 2016, July 5,
2016, March 9, 2017, and April 1, 2018.

18. On or about August 31, 2016, DIANE DUPREE KING, on behalf of
Prestige Creative, certified to Medicare that she would comply with all Medicare
rules and regulations, including that she would not knowingly present or cause to be

presented a false and fraudulent claim for payment by Medicare. She made the same


_ Case 2:21-cr-20494-DML-APP ECF No. 1, PagelD.7 Filed 07/28/21 Page 7 of 13

certification on behalf of Prestige Creative on or about February 22, 2017, and May
4, 2018.

19. Beginning on approximately January 1, 2016, DIANE DUPREE KING
devised and engaged in a scheme to submit false and fraudulent claims to Medicare
for: (a) psychotherapy services that were not provided; (b) psychotherapy services
that were not medically necessary; and/or (c) psychotherapy services that were not
eligible for reimbursement from Medicare.

20. DIANE DUPREE KING submitted, or caused the submission of, false
and fraudulent claims to Medicare purporting that individual and group
psychotherapy was provided to Medicare beneficiaries at Prestige Behavioral and
Prestige Creative facilities, when in fact, the beneficiaries were receiving inpatient
treatment at hospitals on the same dates for which services were billed to Medicare
through Prestige Behavioral and Prestige Creative.

21. DIANE DUPREE KING submitted, or caused the submission of, false
and fraudulent claims to Medicare purporting that individual and group
psychotherapy was provided to Medicare beneficiaries, at both Prestige Behavioral
and Prestige Creative facilities, who suffered from communication deficits requiring
additional accommodations, when, in fact, these beneficiaries did not suffer from

communication deficits and/or no additional accommodations were provided.


_ Case 2:21-cr-20494-DML-APP ECF No. 1, PagelD.8 Filed 07/28/21 Page 8 of 13

22. DIANE DUPREE KING submitted, or caused the submission of, false
and fraudulent claims to Medicare purporting that individual and group
psychotherapy was being provided to Medicare beneficiaries at Prestige Behavioral
and Prestige Creative facilities by Licensed Master Social Workers (“LMSW”)
credentialed by Medicare as providers for Prestige Behavioral and Prestige Creative,
as required by Medicare for reimbursement of these services, when, in fact, these
purported services were provided by unqualified and/or non-credentialed
individuals.

23. DIANE DUPREE KING submitted, or caused the submission of, false
and fraudulent claims to Medicare on behalf of both Prestige Behavioral and Prestige
Creative purporting psychotherapy services were provided by numerous LMSWs,
when, in fact, certain LMSWs were no longer employed by Prestige Behavioral and
Prestige Creative and did not provide the services billed on the submitted claims.

24. DIANE DUPREE KING submitted, or caused the submission of, false
and fraudulent claims to Medicare purporting that beneficiaries were receiving
individual and group psychotherapy, when in fact, beneficiaries did not participate
in individual and/or group therapy because they suffered from conditions that made
it impossible for them to participate and/or benefit from the psychiatric service.

25. DIANE DUPREE KING submitted, or caused the submission of, false

and fraudulent claims to Medicare purporting that beneficiaries were receiving


_ Case 2:21-cr-20494-DML-APP ECF No.1, PagelD.9 Filed 07/28/21 Page 9 of 13

individual and group psychotherapy, when, in fact, staff of Prestige Behavioral and
Prestige Creative played games, assisted beneficiaries with puzzles and painting,
listened to music, and watched television with Medicare beneficiaries, which were
not services covered by Medicare.

26. From on or about January 1, 2016, through present, DIANE DUPREE
KING submitted or caused the submission of at least $6 million in false or fraudulent
claims to Medicare on behalf of Prestige Behavioral and Prestige Creative, all in
violation of 18 U.S.C. §§ 1347 and 2.

EXECUTION OF THE SCHEME AND ARTIFICE

27. On or about the dates specified below, in the Eastern District of
Michigan, and elsewhere, DIANE DUPREE KING, aided and abetted by others, and
aiding and abetting others known and unknown to the Grand Jury, submitted or
caused to be submitted the following false and fraudulent claims to Medicare for
psychotherapy services that were not provided in an attempt to execute, and in
execution of, the scheme as described in Paragraphs 17 to 26, with each execution

set forth below forming a separate count:

Approximate Approximate Description | Approximate
Count | Beneficiary Date of Date of Claim of Items Amount
Service Billed Billed
Count 1 D.R. 11/20/2018 12/6/2018 90834 $100.00
Count 2 D.R 11/20/2018 12/6/2018 90785 $50.00
Count 3 D.R. 11/20/2018 12/6/2018 90853 $50.00
Count 4 L.C. 1/26/2020 3/23/2020 90837 $145.00


Case 2:21-cr-20494-DML-APP ECF No.1, PagelD.10 Filed 07/28/21 Page 10 of 13

Approximate |, . Description | Approximate
Count | Beneficiary Date of SPPros clue of Items Amount
Service Billed Billed
Count 5 I.C. 1/26/2020 3/23/2020 90853 $30.00
Count 6 Y.M. 3/12/2020 4/09/2020 90834 $100.00
Count 7 Y.M. 3/12/2020 4/09/2020 90785 $20.00
Count 8 Y.M. 3/12/2020 4/09/2020 90853 $30.00

Each in violation of 18 U.S.C. §§ 1347 and 2.

FORFEITURE ALLEGATIONS
(18 U.S.C. § 982(a)(7) - Criminal Forfeiture)

28. The allegations contained in this Indictment above are incorporated by
reference as if set forth fully herein for the purpose of alleging forfeiture pursuant to
the provisions of Title 18, United States Code, Section 982.

29. Asa result of the violations alleged in Counts 1 through 8 under Title
18, United States Code, Sections 1347 and 2, defendant DIANE DUPREE KING
shall forfeit to the United States pursuant to Title 18, United States Code, Section
982(a)(7), any property, real or personal, constituting, or derived from, any gross
proceeds obtained, directly or indirectly, as a result of such violation.

30. Substitute Assets: If the property described above as being subject to
forfeiture, as a result of any act or omission of the defendant:

a. Cannot be located upon the exercise of due diligence;
b. Has been transferred or sold to, or deposited with, a third

party;
c. Has been placed beyond the jurisdiction of the Court;

10


Case 2:21-cr-20494-DML-APP ECF No. 1, PagelD.11 Filed 07/28/21 Page 11 of 13

d. Has been substantially diminished in value; or
e. Has been commingled with other property that cannot be
subdivided without difficulty;
it is the intent of the United States, pursuant to Title 21, United States Code, Section
853(p) as incorporated by Title 18, United States Code, Section 982(b), to seek to
forfeit any other property of defendant DIANE DUPREE KING up to the value of
the forfeitable property described above.

31. Money Judgment: Defendant DIANE DUPREE KING shall forfeit to

the United States a sum of money equal to at least $1,547,438.86 million in United
States currency, or such amount as is proved in this matter, representing the total
amount of gross proceeds defendant obtained as a result of defendant’s violations
of Title 18, United States Code, Sections 1347 and 2, as alleged in this Indictment.
THIS IS A TRUE BILL.

s/Grand Jury Foreperson
Grand Jury Foreperson

11


Case 2:21-cr-20494-DML-APP ECF No. 1, PagelD.12

SAIMA S. MOHSIN
ACTING UNITED STATES ATTORNEY

JOSEPH S. BEEMSTERBOER
Acting Chief

Criminal Division, Fraud Section
U.S. Department of Justice

ALLAN J. MEDINA

Chief, Health Care Fraud Unit
Criminal Division, Fraud Section
U.S. Department of Justice

REGINA MCCULLOUGH
Chief, Health Care Fraud Unit
United States Attorney’s Office
Eastern District of Michigan

s/Shankar Ramamurthy

SHANKAR RAMAMURTHY
STEVEN SCOTT

Trial Attorneys

Criminal Division, Fraud Section

U.S. Department of Justice

211 W. Fort Street, Suite 2001

Detroit, MI 48226

Phone: (202) 924-5368

Email: shankar.ramamurthy@usdoj.gov

Dated: July 28, 2021 .

12

Filed 07/28/21 Page 12 of 13

.» Case 2:21-cr-20494-DML-APP ECF No.1, PagelD.13 Filed 07/28/21 Page 13 of 13

Case:2:21-cr-20494

Judge: Lawson, David M.

MJ: Patti, Anthony P.

Filed: 07-28-2021 At 04:34 PM

INDI USA V. SEALED MATTER (DA)

NOTE: It is the responsibility of the Assistant U.S. Attorney signing this form to complete it accurately in all respects.

Eastern District of Michigan

Companion Case Number:

This may be a companion case based upon LCrR 57.10 (b)(4)*: Judge Assigned:
Ll ves No AUSA’s Initials: Sf

Case Title: USA v. Diane Dupree King

County where offense occurred : Wayne County, Oakland County, and Macomb County

Check One: Felony [Misdemeanor [|Petty
V_Indictment/ Information --- no prior complaint.
Indictment/ Information -- based upon prior complaint [Case number: ]
Indictment/ Information --- based upon LCrR 57.10 (d) [Complete Superseding section below].

Superseding to Case No: Judge:

[]Corrects errors; no additional charges or defendants.
[_]Involves, for plea purposes, different charges or adds counts.
[_]Embraces same subject matter but adds the additional defendants or charges below:

Defendant name Charges Prior Complaint (if applicable)

Please take notice that the below listed Assistant United States Attorney is the attorney of record for
the above captioned case.

July 28, 2021 Sp

pate Shankar Ramamurthy, Trial Attorney
211 West Fort Street, Detroit, MI 48226
Phone:(202) 924-5368
Fax: (313) 226-0816
E-Mail address: Shankar.Ramamurthy@usdoj.gov

Attorney Bar #: IL 6306790

1 Companion cases are matters in which it appears that (1) substantially similar evidence will be offered at trial, or (2) the same
or related parties are present, and the cases arise out of the same transaction or occurrence. Cases may be companion cases

even though one of them may have already been terminated.

5/16

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