17-06-2025
Miami-Dade healthcare manager found not guilty at Medicare fraud trial
Two years ago, Kenia Valle Boza's life was upended when prosecutors accused her of conspiring with others to assign falsified codes to medical diagnoses that caused the federal government to pay out millions of dollars for excessive billing.
Valle, a certified professional coder for two Miami-Dade healthcare management companies, was the only defendant named in a conspiracy indictment alleging $12 million in Medicare fraud. Neither doctors who made the diagnoses nor executives who managed Valle went to trial with her.
On Friday, Valle was vindicated when a 12-person federal jury in Miami found her not guilty of conspiracy to commit healthcare and wire fraud, along with three counts of major fraud against the United States. Particularly striking about the verdict was that the jury, after a two-week trial, deliberated for only four hours before acquitting her. U.S. District Judge Kathleen Williams also threw out two wire fraud counts before the jurors began deliberations.
It was a rare trial victory for the defense because federal prosecutors almost always win such cases in South Florida, long recognized as the nation's capital of healthcare fraud.
Valle's defense lawyers, Frank Monsour and Adam Fels, said they were grateful to the jurors for seeing through a criminal case that was based on 'cherry-picked' coding data packaged by prosecutors to make their client look guilty.
'This is not how you prosecute someone in the United States of America,' Monsour told jurors during closing arguments on Friday. 'This is not proof beyond a reasonable doubt. It's offensive. That's what this is. And it permeates this entire case.'
Valle, 41, of West Kendall, worked as a coding manager at Pasteur Medical Center between 2015 and 2017. Pasteur operated several medical clinics in Miami-Dade and Broward counties. After that stint, Valle worked as director of Medicare risk adjustment analytics at HealthSun Health Plans, Inc. until early 2020. HealthSun operated several Medicare Advantage plans serving patients in both counties.
A major part of Valle's job at Pasteur was to ensure that the right codes were assigned to medical diagnoses and procedures for billing to Medicare, the federal insurance program for senior citizens.
The indictment accused Valle of falsely coding several diagnoses, including two particular diagnoses highlighted by prosecutors, to boost Medicare reimbursements by about $12 million. One coding was for 'Other Hemoglobinopathies,' an abnormality in the structure of protein in red blood cells that carry oxygen. The other coding was for 'Disorder of Carbohydrate Metabolism, Unspecified,' a disorder that affects the body's ability to break down carbohydrates.
But at trial, Valle's defense lawyers poked a big hole in the prosecution's case, saying they uncovered data to show that the doctors made those two diagnoses at Pasteur when Valle supervised the coders for billing to Medicare. Moreover, the lawyers said they were able to prove that the codes for risk-adjustment diagnoses generally decreased when Valle managed the coders at Pasteur.
When Valle worked as a Medicare risk-adjustment manager at HealthSun, she was not involved in supervising any healthcare coders, the lawyers said.
They also argued that Valle did not personally benefit from upcoding the diagnoses — that she was paid a 'competitive' salary that ranged from $70,000 to $130,000 over the span of her five years with Pasteur and HealthSun.
Fels told jurors at the outset of the trial that the 'government cannot show any extra money that Kenia received for this alleged fraudulent scheme, not even a dime. ... There are no fancy cars. There are no houses. There are no properties, no bags of cash.
'That's because the evidence is going to show that all Kenia got from working at Pasteur was her hard-earned salary.'
