Case: Doc 1-1 Filed: 06/17/15 1 of 29. PagelD 2 1' 5 9 AFFIDAVIT IN SUPPORT OF APPLICATION FOR.A 'p 5 I, Catherine Hanselman, Special Agent of the United States Department of Health and Human Services, Of?ce of Inspector General, Of?ce of Investigation Cleveland Field Of?ce, being duly sworn, hereby depose and say: INTRODUCTION 1) I make this af?davit in support of an application for a search warrant of the of?ce of Robert Rouzaud, DDS, and Five Points Dental Centre (?Five Points?) at 1026 East 152nd St., Cleveland, Ohio (the The description of the location to be searched is outlined in the following paragraphs and in Attachment A. The items to be seized are listed in Attachments and 3-1. There is probable cause to believe that at the PREMISES there exists evidence of violations or 18 U.S.C. ?1347 (Health Care Fraud). 2) Since February 1997, I have been a Special Agent assigned to conduct health care fraud investigations. I am a law enforcement of?cer of the United States within the meaning of Title 18, US. Code, Section 2510(7), and empowered by law to conduct investigations and to make arrests for federal felony offenses. I have received training at the Federal Law Enforcement Training Center in Georgia, speci?c training in health care fraud investigations, and I am a member of the Northern District of Ohio Health Care Fraud Task Force. 3) In approximately July 2014, I began an investigation of Dentist Robert Rouzaud (hereinafter Rouzaud) and his practice, Five Points Dental Centre. I have been investigating Dr. Rouzaud jointly with the Ohio Attorney General?s Medicaid Fraud Control Unit, the Federal Bureau of Investigation, and the Ohio State Dental Board. 0 Case: Doc 1-1 Filed: 06/17/115 2 of 29. PagelD 3 4) The statements contained in this af?davit are based on information obtained through my personal participation in the investigation, including my review of medical billing information, ?nancial information, surveillance, interviews of patients, interviews of business associates, and business documents from dental supply companies and a billing service, as well as information provided to me by other Special Agents and investigators involved in the investigation. This af?davit is intended to show merely that there is suf?cient probable cause to believe evidence of health care fraud exists at the PREMISES and does not set forth all of the knowledge about this matter. PROBABLE CAUSE Subject ?3 Background 5) On September 29, 1989, the Ohio State Dental Board issued Rouzaud a license to practice dentistry. Rouzaud provides dental services to Medicaid patients in the Northern District of Ohio. 6) Rouzaud operates a practice at 1026 East 152nd St., Cleveland, Ohio 44110. Rouzaud?s practice is called Five Points Dental Centre, though I searched online records maintained by the Ohio Secretary of State and Lexis Nexus and neither Five Points Dental Centre nor Rouzaud are incorporated. Currently, Rouzaud appears to worl< at his practice alone and without any employees. From my experience, dentists normally have of?ce staff who assist them with patients, medical records, and scheduling. 7) Based on the information gathered during my investigation, there is probable cause to believe that Rouzaud has billed for services he does not provide, in violation of 18 U.S.C. 1347 (Health Care Fraud), which prohibits knowingly and willfully executing, and attempting to execute, a scheme and arti?ce to defraud a health care bene?t program, that is, 2 0 Case: Doc 1-1 Filed: 06/17/15 3 of 29. PageID 4 Medicaid, and obtaining, by means of false and fraudulent pretenses, representations and promises, any of the money and property owned by, and under the custody and control of a health care bene?t program, that is Medicaid, in; connection with the delivery of and payment for health care bene?ts and services. Ohio Medicaid and Dental Regulations 8) The Centers for Medicare and Medicaid Services (CMS) is the agency of the United States Department of Health and Human Services (HHS) delegated with the responsibility of administering the Medicare and Medicaid program. 9) Medicaid is a federal health care bene?t program, as de?ned in 18 U.S.C. 24, designated to provide medical services, equipment and supplies to certain individuals and families with low income as outlined in the Social Security Act (42 U.S.C. 1396, et seq.). HHS funds approximately 64% of Ohio?s Medicaid program. The Ohio Department of Medicaid (ODM) administers the Medicaid program in Ohio. The Ohio Medicaid program was previously administered by the Ohio Department of Job and Family Servicesl(ODJFS). For a dentist to be eligible to participate in the Ohio Medicaid program, a provider must have an approved Medicaid provider agreement in accordance with Ohio Administrative Code 5160-1-17. Providers in Ohio claim Medicaid'reimburseme?nt from ODM pursuant to the written provider agreements. 10) In 1989, Rouzaud submitted his original Medicaid provider agreement and ODJFS assigned him billing number On July 7, 2014, Rouzaud signed a revalidation of his Medicaid provider agreement. In this revalidation agreement, Rouzaud listed his of?ce and practice location address as 1026 East 152nd St., Cleveland, Ohio, and an e-mail address of ROBERT Rouzaud agreed to the regulation requiring providers 3 Case: Doc 1-1 Filed: 06/17/15 4 of 29. PagelD 5 to maintain records for a period of six years from the date of receipt of payment based upon those records or until any initiated audit is complete, whichever is longer. Rouzaud also agreed to notify ODM within thirty days of any change in address. 11) signed an Electronic Funds Transfer Agreement with Medicaid on March 3, 2010, to have payments deposited into a Citizen?s Bank account of On July 9, 2010, Rouzaud changed his direct deposit information with Medicaid to Fifth Third Bank Account On May 9, 2014, Rouzaud signed an Electronic Funds Transfer Agreement for deposits to be placed in First Merit Bank Account 12) Medicaid regulations are found in the Ohio Administrative Code, and the Dental Program is covered by Chapter 5160-5. The relevant regulations cover fillings, dentures and extractions: - 5160-5-05: Covered restorative services is restoring a tooth to a normal condition as by ?lling a cavity. Resin is a colored plastic and glass mixture used for ?lling in cavities. Resin can be applied to between one and four surfaces of the tooth. Crowns are restorative procedures that completely cap or encircles the tooth. Prior authorization is required for porcelain fused to noble metal crowns and a radiograph of the tooth must be submitted with each request. Stainless steel crowns shall be allowed only for teeth where multi-surface restorations are needed and amalgam (alloy combination of mercury and one or more metals) restorations and other materials have a poor prognosis. - 5160-5-08: Covered removable prosthodontic services related to dentures. All dentures must be prior authorized. A denture, complete, partial, or combination thereof, shall not be replaced or remade within eight years except for very unusual circumstances. Case: Doc 1-1 Filed: 06/17/15 5 of 29. PagelD 6 5160-5-09: Covered oral surgery services and limitations. The decision to remove a tooth or teeth must be based on the tooth or teeth being too broken down to save, too poorly supported by alveolar bone to save, and/or the presence of some pathological condition which contraindicates saving. Extraction that render a consumer edentulous (having no teeth) must be deferred until authorization to construct a denture has been given, except in absolute emergency situations. Ohio State Dental Board Actions 13) On August 25, 2002, Rouzaud signed a Consent Agreement with the Ohio State Dental Board agreeing to a su5pension of his dental license for 30 days relating to the factual allegations in the Notice of Opportunity for Hearing dated June 12, 2002. In addition to the suspension, Rouzaud agreed to 20 hours of education in dental ethics and 7 hours of infection control training. In the Notice of Opportunity for Hearing relating to an inspection performed on his of?ce on April 19, 2002, the Dental Board found Rouzaud committed ?ve violations: 0 Rouzaud was not using an FDA-approved device or method to sterilize dental instruments. 0 Rouzaud was unable to show evidence of immunity to or immunization against the Hepatitis virus. 0 Rouzaud was not heat sterilizing his high-speed hand pieces and low speed contra-angles between patients. 0 Rouzaud was not properly heat sterilizing hand instruments or items between patients. 0 Rouzaud was not wearing a chin length face shield, mask and eyewear with protective side shields when spattering of blood or other body ?uids was likely. Case: Doc 1-1 Filed: 06/17/15 6 of 29. PagelD 7 14) On February 15, 2005, Rouzaud signed a Consent Agreement admitting to providing the treatments, but not to the conclusion outline, in a September 15, 2004 Notice of Opportunity For Hearing. As a result of this Consent Agreement, Rouzaud agreed to a 120-day suspension of his license. In addition to the suspension, Rouzaud agreed to 21 hours continuing education in diagnosis and treatment planning, 42 hours education in endodontics, and a 200 word essay on the importance of periodontics charting and treatment planning. The Notice of Opportunity cited 21 violations in relation to a review of some of Rouzaud?s patient charts. The Notice included ?ndings that Rouzaud: 0 failed to complete baseline periodontal charting; 0 failed to diagnose and/or treat decay and periapical lesions; 0 performed endodontic procedures that fall below acceptable standard of care; 0 failed to provide preventive treatment; 0 documented on February 29, 2000, in the records for Patient #9 that he placed an MFD alloy on tooth #31, but radiographs dated July 31, 2000, do not show these restorations were completed; 0 documented on June 20, 2001, in the record for Patient #8 that the patient needed $100 of Fixodent to hold in LD, but Rouzaud billed Medicaid for 11 replacements of missing/broken teeth (the records did not show that these repairs were completed); 0 billed Medicaid between January 1, 1996, and June 30, 2001, for new stainless steel crowns when patient records showed that existing stainless steel crowns were readapted and recemented; and Case: Doc 1-1 Filed: 06/17/15 7 of 29. PagelD 8 billed Medicaid between January 1, 1996, and June 30, 2001, for multiple repairs to dentures and partial dentures when the patient?s records re?ected? either that this treatment was not rendered or other treatment was performed and billed as repairs. 15) On September 5, 2005, Rouzaud sent an e-mail from Robert Rouzaud@vahoo.com to the Ohio State Dental Board. The subject of the e-mail was ?Periodontal Essay required per consent agreement.? The title in the body of the e-mail was, ?The Critical Role of Periodontal Charting.? The email contains the following in relevant part: Charting allows the clinician to more objectively determine a patient?s periodontal health status and quantitatively track status changes without inexact assessments such as ?seems better? or ?seems worse.? Highly accurate evaluation of periodontal status lends itself to a more exact prognosis for individual teeth and the entire dentition and directs the dentist to appropriate therapy (therapies). . . . In short, charting accurately addresses the questions of therapy needed at present and outlook for the patient?s oral health in the future. Civil Settlement Agreement 16) On March 26, 2003, Rouzaud signed a Settlement Agreement with the United States Department of Justice, which required him to pay $15,000. In the Agreement, the United States asserted that during a period from January 1, 1997, to December 31, 1999, Rouzaud billed Medicaid for unnecessary restorations on teeth and for the placement of new crowns when the only service performed was a re-attachment of an existing crown. Rouzaud expressly denied the allegation and in signing the Agreement did not agree to an admission of liability. 17) This civil case was based on a sample review of Rouzaud?s billings by the Surveillance and Utilization Review Section at Medicaid. . Misrepresenting Services Provided 18) My investigation reVeals that Rouzaud is misrepresenting the actual services he is providing to Medicaid recipients. He routinely bills for ?llings of teeth which do not require 7 Case: Doc 1-1 Filed: 06/17/15 8 of 29. PagelD 9 pre-authorization when in fact he is not providing this service; instead, he is actually providing other services to patients including dentures, bridges, and extractions, all of which can require pre-authorization from Medicaid. 19) Many of the procedures that Rouzaud is actually providing to patients require Medicaid pre-authorization. According to ODM, all denture-related work must be prior- approved. The approval process takes weeks and requires the dentist, among other things, to send ODM x?raysjustifying the medical necessity of the procedure regardless of whether the request is for a bridge, full upper/lower, partial upper/lower, or just a repair. Once ODM receives the supporting evidence, an ODM dentist approves or denies the request. ODM con?rmed to me that Rouzaud has never requested any type of prior-authorization. 20) Medicaid only pays for one set of dentures per person. In reviewing Rouzaud?s Medicaid billing since August 1, 2011, Rouzaud did not submit to Medicaid any claims for upper or lower complete dentures. 21) Agents obtained Rouzaud?s purchase records from Dentek, Inc., DC Dental, and Moskey Laboratory. The records from Moskey Dental show Rouzaud purchased denture supplies for speci?c patients. The records from Dentek show Rouzaud purchased bridges for speci?c patients. Rouzaud has purchased impression trays, putty, syringe for enamel, and bite registration trays from DC Dental. As described more speci?cally in the Review of Trends in Rouzaud?s Medicaid Billing section below, the supplies ordered from these vendors do not match the ?lling services Rouzaud is billing Medicaid because he orders a lot of crowns, bridges and dentures for speci?c patients but he only bills Medicaid for ?llings. Case: Doc 1-1 Filed: 06/17/15 9 of 29. PagelD 10 Review of Financial Information 22) As part of the investigation, RouZaud?s First Merit Bank Account and Fifth Third Bank Account were reviewed. These accounts both have electronic deposits from Ohio Medicaid. From December 16, 2010, through May 14, 2014, there were 175 electronic deposits totaling $1,225,219.34 from Medicaid into Rouzaud?s Fifth Third account. From May 22, 2014, through July 10, 2014, there were eight electronic payments totaling $64,179.87 from Medicaid deposited into Rouzaud?s First Merit account. 23) My review of ?nancial records indicates that Rouzaud pays his vendors, like Moskey Dental Lab and Dentek, Inc., from the Fifth Third account. This review also con?rms that Rouzaud uses a computer on-line banking program to transfer ?mds. For example, on October 2011, an electronic payment in the amount of $1,141.46 was sent to Dentek, Inc. and on August 31, 2011, an electronic payment in the amount of $1,284.98 was sent to Moskey Dental Lab. 24) From December 12, 201 1, through November 28, 2012, Rouzaud made 11 cash deposits totaling $8,940 into his Fifth Third account. Review of Trends in Rouzaud?s Medicaid Billing 25) From January 1, 2009, through March 31, 2015, Medicaid paid Rouzaud $2.4 million for ?ve types of procedures: Procedure Number Type of Claims Allowed Amount Checkup 66 $1,398.89 Denture/Repair 2,136 $1 1 1,829.66 Extraction 88 $4,556.86 Case: Doc 1-1 Filed: 06/17/15 10 of 29. PagelD 11 Filling 27,485 $2,324,635.84 X-ray 5 $57.00 Total 29780 $2,442,478.25 26) Medicaid requires the provider to identify the recipient, the provider, date of service, place of service, procedure cede, tooth number, and the tooth surface. Medicaid also requires the provider to specify the procedure using standard codes from the American Medical Association (AMA), which created a standardized coding system for all medical providers to use for billing. The AMA assigns and publishes a book of ?ve digit codes, known as Healthcare Common Procedure Coding System codes, that relate to speci?c procedures. The main procedure that Rouzaud bills Medicaid involves a Resin Based Composite, which is a composite ?lling made of ceramic and plastic compounds. The following four billing codes regarding ?llings account for 92% of Rouzaud?s payments by Medicaid: Procedure - Number Allowed Code Procedure Claims Amount Resin-4 or more surfaces D2335 or involv incisal angle 14,361 $1,360,845.30 Resin-based composite- D2332 three surfaces, anterior 6,682 $508,347.08 Resin-based composite- D2394 four or more surf, post 3,446 $26 I ,766.26 Resin-based composite- D2393 three surfaces, posterior 2,970 $192,085.00 27) Rouzaud received a high amount of reimbursement for extreme numbers of ?llings for individual patients. Below is a chart summarizing the top ten patients for whom Rouzaud received reimbursement, which demonstrates an extreme amount of alleged ?llings: 10 Case: Doc 1-1 Filed: 06/17/15 11 of 29. PageID 12 Initial Initial Last First First Date Last Date of Charge Allowed Name Name 'of Service Service Submitted Amount 1/1 1/2009 4/24/2014 $45,025.00 $37,960.92 1 1/2/2009 4/30/2014 $43,586.00 $36,825.50 A 4/27/2009 4/29/2014 $42,090.00 $35,470.70 4/20/2009 4/30/2014 $38,665.00 $33,063.52 1/9/2009 4/24/2014 $39,701.00 $33,056.86 1/2/2009 4/24/2014 $38,050.00 $30,952.78 7/27/2009 5/20/2014 $34,185.00 $29,142.93 9/6/2009 4/30/2014 $33,595.00 $28,804.39 1/19/2009 4/29/2014 $33,915.00 $28,768.08 1/4/2009 4/30/2014 $33,715.00 $28,725.68 28) The patients listed above are included in Attachment B-l. 29) In reviewing the claims for M.S., I found that of the $37,960.02 Rouzaud was paid, $36,688.92 was for resin ?llings. In looking at the 459 claims billed for M.S., Rouzaud billed repeatedly for ?llings on the same tooth. Rouzaud billed separately 32 times for ?lling codes for tooth numbers 7, 8, 9, 1 1, 22, and 27. Rouzaud billed separately 33 ?lling codes each for tooth numbers 10, 23, 24, 25, and 26. Below is a diagram of the mouth to show the location ofthe teeth Rouzaud billed: ll 8 Case: Doc 1-1 Filed: 06/17/15 12 of 29. PagelD 13 30) Agents selected an example involving tooth number 7 and asked dentist Kenneth Jones, an expert consultant for the Ohio State Dental Board, about Dr. Rouzaud?s billing, and Jones opined that it was not plausible that Rouzaud did what his billing indicates. 31) According to Dentek purchase records, Rouzaud ordered the following supplies for M.S.: 2009 records showed Rouzaud purchased for MS. bridge posterior/anterior and an adjustment to the bridge. 0 2012 records showed Rouzaud purchased for MS. dowel post and single Porcelain Fused Metal (PFM) anterior. 2015 records showed Rouzaud purchased for MS. dowel post/talladium. 32) In reviewing the claims for LG, the $36,825.50 Rouzaud was paid, $36,448.05 was for resin ?llings. In looking at the 436 claims billed for LG, Rouzaud billed repeatedly for ?llings on the same tooth. For example, Rouzaud billed for 30 ?lling codes on tooth number 6; 29 ?lling codes each for tooth numbers 7, 8, 10; 28 ?lling codes for tooth number 9; and 27 ?lling codes each for tooth numbers 23 and 24. 33) According to Dentek purchase records, Rouzaud ordered the following supplies for LG: 0 in 2010, dowel post and single PFM anterior/posterior. in 2011, dowel post. 0 in 2012, dowel post and single PFM posterior. in 2014, single PFM posterior. 12 Case: Doc #1 1-1 Filed: 06/17/15 13 0129. PagelD 14 34) Rouzaud has billed for ?llings for patients who have previously been billed for a full set of dentures by another Medicaid provider. Below is a summary of ?llings Rouzaud billed for patients after they received ?all sets of dentures: irst Date Rouzaud Date Dentures Initial Treatment A Provided from Last First (Post LastDate Allowed Other Provider Name Name Dentures) of Service Claims Amount 2/17/2012 3/2/2012 4/28/2014 56 $4,887.27 . 6/4/2012 2/17/2014 4/11/2014 45 $4,052.79 1/7/2009 5/8/2012 4/29/2014 87 $7,433 .61 6/24/201 1 5/30/2012 4/30/2014 49 $4,100.54 35) Rouzaud has billed Medicaid for ?llings for 16 teeth for which other Medicaid providers had previously billed for an extraction. For example, recipient S.A. had tooth number 12 extracted by another provider on January 27, 2012. Rouzaud billed Medicaid after this extraction for 6 ?llings on tooth number 12 and Medicaid paid him $424.62. 36) Included in Attachment B-l are the patients that Rouzaud billed for ?llings who previously had the tooth billed removed and patients who have full dentures. Interviews 37) On March 30, 2015, agents interviewed M.H., the Supervisor/Manager at Business Medical Services (EMS). M.H. stated BMS provides medical billing and medical record keeping services. M.H. is familiar with Rouzaud and has spoken with Rouzaud several times via the telephone. M.H. stated Dr. Rouzaud has used BMS to perform medical billing for his dental practice since 2008. Rouzaud submits dental claims to EMS via a Medicaid Claim Form numbered 06780. Rouzaud ?lls out these fOrms manually and faxes them to EMS multiple times per week. M.H. stated after Dr..Rouzaud faxes in the claim forms to EMS, he calls BMS 13 1 Case: Doc 1-1 Filed: 06/17/15 14 of 29. PagelD 15 to ensure that the fax was received. Rouzaud completes a single Medicaid Claim Form for each patient with the billing codes. Once the Medicaid Claim Forms have been received by EMS, BMS employees place the information from the Medicaid Claim Forms into a computer application to electronically bill Medicaid for the services. 38) On March 16, 2015-, agents interviewed R.L., the President of Moskey Dental Laboratories (Moskey), which is a full service dental supplier that manufactures custom dental crowns, dentures, and implants. According to R.L., Rouzaud has been a customer of Moskey for a long time. R.L. said Rouzaud?s of?ce is located at the Five Points Shopping Center in the Collinwood neighborhood. Moskey operates a delivery service that picks up the prescription order and dental impression from Rouzaud and then delivers the ?nished product. In reviewing Rouzaud?s purchases, R.L. stated that Rouzaud primarily orders new, partial, or repair dentures. R.L. stated Rouzaud places approximately 15 regular orders with Moskey each month. 39) Agents interviewed F.D. on March 31?, 2015, about services she received from Rouzaud. F.D. stated Rouzaud?s of?ce is located next to Family Foods on East 152'"1 street. F.D. described the interior of Rouzaud?sof?ce as ?ragged.? She stated that when one walks into Rouzaud?s of?ce, there is a desk in the front. The exam chair has an x-ray machine mounted to the wall next to the chair. The arm of the its-ray can be'brought by your mouth while in the chair. F.D. stated there is a room in the back of the of?ce with a cooking stove. F.D. stated that Rouzaud works in the of?ce by himself and does not have a secretary; Rouzaud answers the telephone and schedules appointments. When F.D. came into the office for her most recent visit, Rouzaud took her insurance information. 40) FD. showed the interviewing agents appointment cards from her last visits, which indicated visit dates of May 6 and May 15 for 10:00 am; the cards did not indicate the year. FD. 14 Case: Doc 1-1 Filed: 06/17/15 15 of 29. PagelD 16 told the agents that she saw Rouzaud in May 2014 because she had pain in two of her bottom left side teeth. F.D. went to Rouzaud because she wanted him to pull the teeth out. 41) On May 6, 2014, .D. went to Rouzaud?s o??ice. On this visit, .D. told Rouzaud about her tooth pain and the desire to have the teeth removed. Rouzaud cleaned her teeth and did I x-rays. Rouzaud then scheduled .D. to return to the of?ce on May 15, 2014, to have the teeth removed. 42) On May 15, 2014, RD. went to the of?ce to have the teeth removed. Rouzaud gave her three shots of a local anesthetic prior to removing the teeth. A?er Rouzaud removed the teeth, Rouzaud wrote F.D. a prescription for antibiotics. 43) According to Medicaid billing records, Rouzaud billed for services for F.D. on April 30, 2014, and May 6, 2014. On April 30, 2014, Rouzaud billed code D2335 (Resin- . 4 or more surfaces) on tooth numbers and code D2394 (Resin-based composite-4 or more surfaces) for tooth numbers 12, 13, 15, 16, 20 and Medicaid paid Rouzaud $1,028.94 for the services he billed on April 30, 2014. 44) On May 6, 2014, Rouzaud billed code D2335 for tooth numbers 22, 23, 24, 25, 26, and 27, but Medicaid denied payment because on May 1, 2014, insurance coverage changed from fee-for-service Medicaid to a Medicaid HMO in order for Rouzaud to bill the new Medicaid HMO, Rouzaud would have needed to have a provider agreement with the new plan, which he did not have. Based on thesefacts, I believe it is possible that Rouzaud changed the actual date he treated F.D. to April 30, 2014, so that he was still able to bill. 45) The interviewing agents told F.D. that Rouzaud billed for multiple ?llings for these visits. F.D. stated that Rouzaud did not provide any ?llings to her and that the problematic teeth were removed. 15 Case: Doc 1-1 Filed: 06/17/15 16 of 29. PagelD 17 46) Below is a summary of the services, billing codes, and reimbursement amounts that would have applied to the procedures Rouzaud actually provided to F.D. compared to the $1,028.94 that was paid: CODE DESCRIPTION REIMBURSEMENT D1 1 10 Prophylaxis (cleaning) $34.13 Bitewing x?ray 2 D0272 lmages $10.00 D0120 Periodic oral exam $17.08 D7140 Extraction $52.45 D7140 Extraction $52.45 Total $166.11 47) On April 16, 2015, agents interviewed D.M. and L.M., husband and wife, about services they received from Rouzaud. The M.?s speak Russian and an FBI interpreter translated the interview. L.M. stated she recalled seeing Rouzaud for dental visits in the years 2013 and 2014. L.M. stated she had crowns and ?llings on both her upper and lower teeth done by her previous dentist. 48) L.M. stated Rouzaud offered to remove all of her teeth and provide her with full dentures. L.M. refused this proposal because she believed her teeth could be salvaged and ?xed with bridges. L.M. stated that Rouzaud took a long time to do his dental procedures because it was difficult to get appointments andthe appointments were scheduled very far apart from each other. She said Rouzaud traveled frequently back to Israel. L.M. stated that it was common for Rouzaud to leave L.M. with open wounds following the partial completion of a bridge and these wounds became infected. L.M. took anti-biotic medication to treat the infection, but the anti- biotic didn?t work, and L.M. developed gum disease. L.M. stated she was deSperate to have Rouzaud ?x her teeth and gums and stop the pain, but she had great dif?culty getting an appointment. 16 Case: Doc 1-1 Filed: 06/17/15 17 of 29. PageID 18 49?) L.M. stated Rouzaud had poor sanitary conditions in his dental of?ce. L.M. was a medic in Russia and said she understands proper sanitary conditions. None of the equipment Rouzaud used was sterile. L.M. stated Rouzaud worked by himself during the dental procedure. Rouzaud had L.M. hold dental instruments. L.M. stated she did not believe this was sanitary because her hands were not clean. During procedures with Rouzaud, saliva and spit ran down the sides of mouth because Rouzaud did not use the equipment needed to clear the saliva and spit out of her mouth. 50) L.M. stated she has a bridge on her upper and lower teeth. stated a tooth cracked next to her lower bridge and this tooth was hurting. L.M. wanted Rouzaud to ?x the tooth, but Rouzaud instead removed this tooth. Rouzaud pulled the last tooth on the bottom right side of her mouth. 51) L.M. stated she only had two ?llings done by Rouzaud. Both of the ?llings were on the same tooth, which is located in her. upper jaw in the back of her mouth. The ?llings were done in approximately the summer of 2014 or in the early fall of 2014. L.M. stated Rouzaud did a poor job and both ?llings fell out the day after Rouzaud put them in. 52) Rouzaud did X-rays on? mouth prior to making impressions and casts of her teeth. Rouzaud had a hard time making the mouthpiece which caused irritation inside her mouth. L.M. stated Rouzaud used too big of a mouthpiece for the dental impression. 53) L.M. had a problem with a bridge Rouzaud did on her upper teeth. The bridge broke one week after Rouzaud installed it. L.M. stated she had a lower bridge done by Rouzaud and it had a part that was missing and had a rod sticking out of it. Rouzaud blamed the missing part on the vendor. L.M. stated she had to ?le this rod down on her own because it was very l7 Case: Doc 1-1 Filed: 06/17/15 18 of 29. PagelD 19 uncomfortable. L.M. had four cracked teeth and Rouzaud connected them via a bridge that had open metal on top of the bridge. L.M. stated she now only tastes metal in her mouth. 54) L.M. did not discuss with Rouzaud how he billed the procedures. Rouzaud never told her that he was going to bill for ?llings for the bridge work. 55) Sometime in 2013, L.M. paid Rouzaud $200 in cash. L.M. stated Rouzaud had hinted to her that he wanted money. L.M. put $200 cash in an envelope and gave it to Rouzaud in his of?ce and he accepted it. 56) In 2014, Rouzaud told L.M. that he needed money from her because he needed to . pay for the lab technicians who make his supplies. L.M. initially paid Rouzaud $250 in cash in an envelope. Rouzaud took the envelope and went on the other side of the divider in the of?ce to count the money. Rouzaud counted and then told L.M. that $250 wasn?t enough money. L.M. stated she then provided Rouzaud with $500 total cash in an envelope and he took this money on the other side of the of?ce divider to count. L.M. said she knows it isn?t right to pay Rouzaud money, but she paid him because she needed him to ?x a cracked bridge on the left side of her mouth. 57) D.M. stated that he did not like Rouzaud because his of?ce was not organized, not clean, and not professional. 58) D.M. had two teeth removed by his previous dentist. Rouzaud removed two additional healthy teeth in the upper jaw side of his mouth in order to make a full set of dentures. D.M. could not recall the dates of these procedures. Rouzaud never did any ?llings on D.M. D.M. took out a full set of dentures from his upper mouth and showed the interviewing agents. Rouzaud initially took an x-ray and made an impression of teeth. The impression was made of gypsum, and Rouzaud sent it to a lab. D.M. stated the denture needed to be sent back to 18 Case: Doc 1-1 Filed: 06/17/15 19 of 29. PagelD 20 the lab approximately four times to tune it up and make it ?t properly. Rouzaud blamed the dental technicians at the dental lab for not getting it to ?t right on the ?rst, second, or third time. D.M. did not have any issues with his?bottom teeth. D.M. stated his bottom teeth were previously worked on by a dentist in Ukraine. 59) L.M. and D.M. were shown a picture of the front door of Rouzaud's dental of?ce located at 1026 E. 152nd Street, Cleveland, Ohio, during the interview. L.M. and D.M. both con?rmed that this is where they received dental procedures from Rouzaud. L.M. stated she never saw Rouzaud document his dental work in a physical medical ?le. L.M. stated she did observe Rouzaud use a laptOp computer in his dental of?ce while she was there at an appointment. Rouzaud had a handwritten scheduling book at his of?ce for appointments. 60) Rouzaud?s collection of cash payment from is a violation of Medicaid regulations. Medicaid regulations and the Medicaid provider agreement outline that payment from Medicaid constitutes payment in full for any covered services and the provider will not charge the member any co-payment, cost sharing, down payment, or similar charge, refundable or otherwise. These regulations are set forth in Ohio Administrative Code Sections 5160-1-60, 5160-1?09 and 5160-26-01. 61) Rouzaud billed Medicaid for 224 claims from September 26, 2011, through April 30, 2014, for L.M. and Medicaid paid Rouzaud $17,660. The only teeth that Rouzaud did not bill for ?llings were tooth numbers 1, 15, 16, and 17. Rouzaud billed for 15 ?lling codes each for tooth numbers 6, 7, and 9; 16 ?lling codes for tooth number 8; l4 ?lling codes for tooth number 1 1; and 13 ?lling codes each for tooth numbers 22, 23, 24, 26, and 27. 62) According to Dentek purchase records, Rouzaud ordered the following supplies for L.M.: 19 Case: Doc 1-1 Filed: 06/17/15 20 of 29. PagelD 21 in 2011, bridge PF anterior/posterior and reshape in 2012, remake PFM bridge posterior/anterior, bridge PFM posterior/anterior, and post dowel. in 2013, bridge PFM anterior/posterior, metal ?ame, and dowel post. 63) Rouzaud billed Medicaid for 32 ?lling codes and a cleaning for D.M. from November 22, 2011, through November 7, 2013, and Medicaid paid Rouzaud 71.24. 64) The Medicaid patients interviewed by agents are included in Attachment 8-1. I have also included in Attachment B-l a random sample of patients from Medicaid for whom Rouzaud billed ?llings. Surveillance 65) From February 24, 2015, through March 11, 2015, a video surveillance camera was mounted on an electric pole on a public street across from 1026 East 152nd St., Cleveland, Ohio. During that time, Rouzaud exited a car registered in his name and entered the PREMISES. Rouzaud removed a briefcase from his car and carried it into the dental of?ce. 66) From the video, Rouzaud does not appear to maintain any set of?ce hours and there were days of the week in which he never came. Patients were seen entering and exiting the of?ce. Some of the patients were transported to and from the of?ce by independently operated transportation companies. COMPUTER INFORMATION 67) Your af?ant?s training and experience have shown that individuals and businesses, particularly health care providers, typically use computers to facilitate record keeping and to record business transactions. In addition, Rouzaud provided an e-mail address to Medicaid and the Ohio State DentalBoard. A patient saw Rouzaud use a laptop in his of?ce. . 20 h~ Case: Doc 1-1 Filed: 06/17/15 21 of 29. PagelD 22 And bank account information shows Rouzaud made on?line electronic transfers. Therefore, your af?ant believes that Rouzaud uses a computer to facilitate his scheme to defraud Medicaid. Computers, Electronic Storage, and Forensic Analysis 68) As described above and in Attachment B, this application seeks permission to search for records that might be found on the PREMISES, in whatever form they are found. One form in which the records might be found is data stored on a computer?s hard drive or other storage media. Thus, the warrant applied for would authorize the seizure of electronic storage media or, potentially, the copying of electronically stored information, all under Rule 69) Probable cause. I submit that if a computer or storage medium is found on the PREMISES, there is probable cause to believe those records will be stored on that computer or storage medium, for at least the following reasons: Based on my knowledge, training, and experience, I know that computer ?les or remnants of such ?les can be recovered months or even years after they have been downloaded onto a storage medium, deleted, or viewed via the Internet. Electronic ?les downloaded to a storage medium can be stored for years at little or no cost. Even when ?les have been deleted, they can be recovered months or years later using forensic tools. This is so because when a person ?deletes? a ?le on a computer, the data contained in the ?le does not actually disappear; rather, that data remains on the storage medium until it is overwritten by new data. b) Therefore, deleted ?les, or remnants of deleted ?les, may reside in free space or slack space?that is, in space on the storage medium that is not currently being used by an active ?le?for long periods of time before they are overwritten. In addition, a 21 d) Case: Doc 1-1 Filed: 06/17/15 22 of 29. PagelD 23 computer?s operating system may also keep a record of deleted data in a ?swap? or ?recovery? ?le. Wholly apart from user-generated ?les, computer storage media?in particular, computers? internal hard drives?contain electronic evidence of how a computer has been used, what it has been used for, and who has used it. To give a few examples, this forensic evidence can take the form of Operating system con?gurations, artifacts from operating system or application operation, ?le system data structures, and virtual memory ?swap? or paging ?les. Computer users typically do not erase or delete this evidence, because Special software is typically required for that task. However, it is technically possible to delete this information. Similarly, ?les that have been viewed via the Internet are sometimes automatically downloaded into a temporary Internet directory or ?cache.? Based on actual inspection of other evidence related to this investigation, as described above, I am aware that computer equipment was used to generate, store, and print documents used in the health care fraud scheme. There is reason to believe that there is a computer system currently located on the PREMISES. 70) Forensic evidence. As further described in Attachment B, this application seeks permission to locate not only computer ?les that might serve as direct evidence of the crimes described on the warrant, but also for forensic electronic evidence that establishes how computers were used, the purpose of their use, who used' them, and when. There is probable cause to believe that this forensic electronic evidence will be on any storage medium in the PREMISES because: 22 Case: Doc 1-1 Filed: 06/17/15 23 of 29. PagelD 24 a) Data on the storage medium can provide?evidenCe of a ?le that was once on the storage b) medium but has since been deleted or edited, or of a deleted portion of a ?le (such as a paragraph that has been deleted from a word processing Virtual memory paging systems can leave traces of information on the storage medium that show what tasks and processes were recently active. Web browsers, e?mail programs, and chat programs store con?guration information on the storage medium that can reveal information such as online nicknames and passwords. Operating systems can record additional information, such as the attachment of peripherals, the attachment of USB ?ash storage devices or other external storage media, and the times the computer was in use. Computer ?le systems can record information about the dates ?les were created and the sequence in which they were created, although this information can later be falsi?ed. As explained herein, information stored within a computer and other electronic storage media may provide crucial evidence of the ?who, what, why, when, where, and how? of the criminal conduct under investigation, thus enabling the United States to establish and prove each element or alternatively, to exclude the innocent from further suSpicion. In my training and experience, information stored within a computer or storage media registry information, communications, images and movies, transactional information, records of session times and durations, intemet history, and anti-virus, spyware, and malware detection programs) can indicate who has used or controlled the computer or storage media. This ?user attribution? evidence is analogous to the search for ?indicia of occupancy? while executing a search warrant at a residence. The existence or absence of anti-virus, spyware, and malware detection programs may indicate whether the computer was remotely accessed, thus inculpating or exculpating the computer owner. Further, 23 Case: Doc 1-1 Filed: 06/17/15 24 of 29. PagelD 25 computer and storage media activity can indicate how and when the computer or storage media was accessed or used. For example, as described herein, computers typically contain information that log: computer user account session times and durations, computer activity associated with user accounts, electronic storage media that connected with the computer, and the IP addresses through which the computer accessed networks and the intemet. Such information allows investigators to understand the chronological context of computer or electronic storage media access, use, and events relating to the crime under investigation. Additionally, some information stored within a computer or electronic storage media may provide crucial evidence relating to the physical location of other evidence and the suspect. For example, images stored on a computer may both show a particular location and have geolocation information incorporated into its ?le data. Such ?le data typically also contains information indicating when the ?le or image was created. The existence of such image ?les, along with external device connection logs, may also indicate the presence of additional electronic storage media a digital camera or cellular phone with an incorporated camera). The geographic and timeline information described herein may either inculpate or exculpate the computer user. Last, information stored within a computer may provide relevant insight into the computer user?s state of mind as it relates to the offense under investigation. For example, information within the computer may indicate the owner?s motive and intent to commit a crime intemet searches indicating criminal planning), or consciousness of guilt running a ?wiping? program to destroy evidence on the computer or password such evidence in an effort to conceal it from law enforcement). 24 Case: Doc 1-1 Filed: 06/17/15 25 of 29. PagelD 26 c) d) A person with appropriate familiarity with how a computer works can, after examining this forensic evidence in its proper cOntext, draw conclusions about how computers were used, the purpose of their use, who used them, and when. The process of identifying the exact ?les, blocks, registry entries, logs, or other forms of forensic evidence on a storage medium that are necessary to draw an accurate conclusion is a dynamic process. While it is possible to specify in advance the records to be sought, computer evidence is not always data that can be merely reviewed by a review team and passed along to investigators. Whether data stored on a computer is evidence may depend on other information stored on the computer and the application of knowledge about how a computer behaves. Therefore, contextual information necessary to understand other evidence also falls within the scope of the warrant. Further, in ?nding evidence of how a computer was used, the purpose of its use, who used it, and when, sometimes it is necessary to establish that a particular thing is not present on a storage medium. For example, the presence or absence of counter-forensic programs or anti-virus programs (and associated data) may be relevant to establishing the user? 3 intent. 7l) Necessity of seizing or copying entire computers or storage media. In most cases, a thorough search of a premises for information that might be stored on storage media often requires the seizure of the physical storage media and later off-site review consistent with the warrant. In lieu of removing storage media from the PREMISES, it is sometimes possible to make an image copy of storage media. Generally speaking, imaging is the taking of a complete electronic picture of the computer?s data, including all hidden sectors and deleted ?les. Either seizure or imaging is often necessary to ensure the accuracy and completeness of data recorded 25 Case: Doc 1-1 Filed: 06/17/15 26 of 29. PagelD 27 on the storage media, and to prevent the loss of the data either from accidental or intentional destruction. This is true because of the following: a) b) The time required for an examination. As noted above, not all evidence takes the form of documents and files that can be easily viewed on site. Analyzing evidence of how a computer has been used, what it has been used for, and who has used it requires considerable time, and taking that much time on premises could be unreasonable. As explained above, because the warrant calls for forensic electronic evidence, it is exceedingly likely that it will be necessary to thoroughly examine storage media to obtain evidence. Storage media can store a large volume of information. Reviewing that information for things described in the warrant can take weeks or months, depending on the volume of data stored, and would be impractical and invasive to attempt on-site. Technical requirements. Computers can be con?gured in several different ways, featuring a variety of different operating systems, application software, and con?gurations. Therefore, searching them sometimes requires tools or knowledge that might not be present on the search site. The vast array of computer hardware and software available makes it dif?cult to know before a search what tools or knowledge will be required to analyze the system and its data on the Premises. However, taking the storage media off-site and reviewing it in a controlled environment will allow its examination with the proper tools and knowledge. Variety of forms of electronic media. Records sought under this warrant could be stored in a variety of storage media formats that may require off-site reviewing with specialized forensic tools. I 26? Case: Doc 1-1 Filed: 06/17/15 27 of 29. PagelD 28 72) Nature of examination. Based on the foregoing, and consistent with Rule the warrant I am applying for would permit seizing, imaging, or otherwise copying storage media that reasonably appear to contain Some or all of the evidence described in the warrant, and would authorize a later review of the media or information consistent with the warrant. The later review may require techniques, including but not limited to computer-assisted scans of the entire medium, that might expose many parts of a hard drive to human inspection in order to determine whether it is evidence described by the warrant. 73) Five Points is a functioning company that renders dental care. The seizure of Five Points? computer(s) may limit Rouzaud?s ability to conduct his legitimate business. In light of these concerns, the search team will evaluate incrementally the necessity of sizing Rouzad?s computer hardware, software and storage media being used to operate the dental practice. a) Upon arriving at the PREMISES on the day of the search, the search team will attempt to identify a system administrator (or other knowledgeable individual) willing to assist law enforcement in creating an electronic ?image? of those sections or parts of Rouzaud?s computer hardware, software and storage media that are likely to store records and data speci?ed in the warrant (I do not believe Rouzaud employs such a person, but the search team will inquire and will consult with Rouzaud of no one else can assist). Generally speaking, imaging is the taking of a complete electronic duplicate of the computer?s data, including all hidden sectors and deleted ?les. Imaging a computer permits the agents to obtain an exact duplicate copy of the computer?s stored data without actually seizing the computer hardware. A computer expert will then conduct an off-site search for records and data speci?ed in the warrant from the ?mirror image? copy at a later date. The search team will not remove computer hardware, software and electronic storage media from the 27 Case: Doc 1-1 Filed: 06/17/15 28 of 29. PagelD 29 19) PREMISES if it is able to successfully image those portions which are necessary to the successful execution of the warrant. If the knowledgeable individual(s) are unable or unwilling to assist the search team in locating all of the records and data speci?ed in the warrant or if the search team has doubts as to whether the assisting individual(s) have been fully forthcoming, the search team will try, on its own, to identity and image those parts of the computer hardware, software and storage media that are likely to store records and data speci?ed in the warrant. If ?on-site imaging? proves impractical or impossible for any reason, then the search team will seize computer hardware, software, and storage media that is necessary to locate the records, data and other information set forth in the warrant, at an off-site location. Records and data, or c0pies of records and data, which are not contraband or evidence of a crime will be returned as set forth in Attachment B, which is incorporated herein by reference. DISCLOSURE OF INFORMATION 74) Based upon my knowledge, experience and training, I know that medical providers, such as Rouzaud, keep documents related to their medical patients and billings for services provided. We, as part of this investigation and pursuant to facts detailed in this af?davit, seek to seize all documents listed in Attachments and 3-1 for the time period January 01, 2009, through the present date. 75) A reasonable and good faith effort will be made to protect the con?dentiality of patient information obtained in any and all property that is seized. Investigating agents, government attorneys, or their designees, will disclose only such information as is necessary to 28 Case: Doc 1-1 Filed: 06/17/15 29 of 29. PageID 30 complete the criminal investigation and any subsequent prosecution which may result from this matter, without compromising the integrity of this process. ACCESS TO RECORDS FOR THE CONTINUED TREATMENT OF PATIENTS 76) The following procedures with reSpect to the seizure of patient ?les listed in Attachment B-l, Rouzaud will be noti?ed that c0pies will be made on an ?as needed? basis according to the following protocol: (1) if Rouzaud needs a patient ?le, a fax request should be made to the attention of Special Agent Catherine l-lanselman at (216) 522?3429, and agents will provide Rouzaud or his attorney with a c0py ofthe requested ?le; and (2) ifa patient needs access to his/her ?le, the patient should call Special Agent Catherine Hanselman at (216) S22- 3455 to make the request, and upon receipt ofa valid patient release form signed by Rouzaud, agents will provide the patient with a c0py of the requested ?le. . CONCLUSION 77) Special Agent Catherine Hanselman, US. Department of Health Human Services, being duly sworn according to law, deposes, and says that the facts stated in the foregoing Af?davit are true and correct to the best of her knowledge, information and belief. ReSpectfullv submitted, Catherine Hanselman Special Agent SWORN TO AND SUBSCRIBED TO BEFORE ME THIS 4 2 -th DAY OF June, 2015 my A. cchiareili IITED TATES MAGISTRATE JUDGE Northern District of Ohio 29