Women charged with defrauding Culinary Union insurance program

By Mary Manning

Thursday, April 23, 2009 | 11:50 a.m.

Two California women and two Las Vegas women have been charged with organizing, and in some cases, participating in a scheme to defraud the local Culinary Union's health insurance program.

The women submitted claims for unauthorized cosmetic surgeries performed on union members in Mexico, said U.S. Attorney Greg Brower of Nevada.

Rebecca Acosta, 46, of Chula Vista, Calif., was indicted Wednesday by a federal grand jury on three counts of mail fraud. Acosta was arrested April 14 in San Diego and released Wednesday on a $150,000 surety bond.

Three other women have been charged by criminal complaint for their involvement in the scheme, Brower said.

Ana Bertha Acosta, 39, of Dulzura, Calif., was arrested Monday in San Ysidro, Calif., and Sara Casales, 47, of Las Vegas was arrested April 14 in Las Vegas. Both are charged with health care fraud and aiding and abetting.

Lucia Solano, 49, of Las Vegas, also arrested April 14 in Las Vegas, is charged with making false statements to investigators.

In 2006 federal investigators initiated an investigation to determine if Las Vegas insurance providers were being targeted for fraudulent medical claims by Mexican medical providers, according to court records.

The investigators found that the Hotel and Restaurant Employees International Union Welfare Fund, also known as the Culinary Fund, which offers medical insurance to at least 50,000 people in the hospitality industry in Las Vegas, had been billed about $4.9 million for "out of country" claims from about January 2002 to February 2006.

Those "out of country" claims were almost entirely from Mexico, investigators discovered. Most of the claims were for emergency procedures in Mexico.

When investigators began interviewing a number of the patients, they were told that the insurance claims were fabricated and that they had actually had cosmetic surgery in Mexico, not emergency services. The Culinary Fund does not provide coverage for cosmetic surgeries, unless they are medically necessary.

Rebecca Acosta and her cohorts allegedly devised a scheme to defraud the Culinary Fund of money through submitting false health care claims. Acosta and the others met with prospective patients at a Summerlin residence and elsewhere for consulting on cosmetic surgeries, court documents say.

Acosta told prospective patients that she and the others could arrange for the Culinary Fund health insurance program to pay for cosmetic procedures, such as breast augmentations or "tummy tucks," even though such procedures were not covered through the insurance program.

Acosta told the patients that she would bill the Culinary Fund for the cosmetic procedures, but would make it appear as if the patient suffered an unexpected injury in Mexico and had received emergency medical care.

Acosta allegedly made arrangements for the prospective patients to receive a cosmetic procedure at a Tijuana, Mexico, clinic. Then she charged the patients a fee in addition to any reimbursement they would receive from the Culinary Fund. Acosta instructed each patient not to disclose the true nature of the treatment they received in Tijuana.

Once the patients received treatments in Tijuana, Acosta and the others submitted false and fraudulent claims to the Culinary Fund, requesting reimbursement for emergency medical services, even though they knew that the patients had actually received cosmetic procedures, court documents state.

Between September and October 2005, Acosta allegedly submitted three fraudulent claims for reimbursement for emergency procedures performed on three patients and the Culinary Fund paid more than $42,000 on the claims.

If convicted, Acosta faces up to 20 years in prison and a $250,000 fine on each count; Ana Bertha Acosta and Sara Casales face up to 10 years in prison and a $250,000 fine each; and Lucia Solano faces up to five years in prison and a $250,000 fine.

The case is being investigated by the Office of Inspector General for the U.S. Department of Labor, and the U.S. Postal Inspection Service. It is being prosecuted by Assistant U.S. Attorney Crane Pomerantz.

"This indictment sends a stern message to those medical providers that defrauding union health and welfare benefit plans by filing fraudulent claims will not be tolerated by my agency," said Daniel R. Petrole, deputy inspector general for the U.S. Department of Labor. "We are firmly committed to working with other law enforcement agencies to investigate this type of crime."