FRAUD (WA)- West Richland WA couple accused of $700,000 in Medicaid fraud

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[MM Curator Summary]: A husband and wife couple stole a ton of cash. This story even includes a few good ole fashioned stake outs.



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By Cameron Probert

September 30, 2023 5:00 AM

Richland, WA

A West Richland couple allegedly led a criminal organization that bilked Medicaid for more than $700,000, according to a Washington state investigation.

Cloreese Wilkinson-Rivera, 46, and Carlos P. Rivera, 44, allegedly spent three years creating phantom therapy appointments, billing the wrong amounts to insurance companies and charging for appointments that never happened, according to recently filed court documents.

They used the money to pay for their home and at least five luxury cars, including two Ferraris and a Lamborghini.

After a lengthy investigation, the Washington State Attorney General’s Office filed 17 counts against the couple in Benton County Superior Court.

They are accused of leading a criminal organization, five counts of theft, five counts of money laundering and submitting false statements to Medicaid.

Wilkinson-Rivera also faces one count of forgery.

They have both been summoned to court to enter pleas to the charges on Oct. 19.

The couple ran Tri-Cities Marital and Family Therapy from an office building on Stevens Drive in Richland, according to public records.

The investigation also includes a Kennewick location where they operated previously.

Wilkinson-Rivera led a team of counselors, and Rivera ran the business, including billing, according to court documents.

Wilkinson-Rivera has had a lengthy career providing mental health services that began in 2004, according to her profile on Psychology Today. She has served as a bilingual clinician, a vocational rehabilitation counselor, a daycare provider and a hospital case manager.

Department of Health records say she became a licensed mental health counselor in 2015, and, according to the state attorney general, the alleged theft started shortly after.

Fraudulent billing

The state’s Medicaid Fraud Control Division started investigating the couple after getting a tip from a former co-worker, said Special Agent Ses Maiava in an affidavit.

The tipster said Wilkinson-Rivera was double billing for services not rendered. That including billing an entire family for therapy, but only treating one person.

Investigators soon discovered the couple was submitting Medicaid billing claims that misrepresented what they were doing, and raked in $710,000 between January 2016 and June 2019.

That included billing for patients who missed, skipped or canceled appointments, using incorrect billing codes, and submitting claims for hour-long sessions that were, in reality, much shorter.

The alleged fraudulent billing also included people who were never treated by anyone at the Tri-Cities Marital and Family Therapy.

“Sometimes these billings would correspond with family member’s treatments, but other times there would be a claim that was paid without any reason for it to be billed,” Maiava wrote. “I refer to these claims as ‘Phantom Billings.'”

Billing more than 24 hours

After getting the tip, a fiscal expert went through the billing statements that Wilkinson-Rivera had sent in and allegedly found she would have been working for more than 24 hours in a day.

State investigators watched Wilkinson-Rivera go into the office during three separate three-day periods in October 2018, January 2019 and March 2019. Each time, she billed for dozens of hours that she wasn’t working at the building.

During the surveillance in January, agents counted 44 people enter the facility, while Medicaid billing records allegedly showed them treating 133.

The records also showed she allegedly billed a family of five who had a group therapy, as if each member was treated during a separate 60-minute session.

In another case during the January period, a family of five was billed for a therapy session they never attended. In another family, one child received therapy, but then the child’s two siblings were also billed for individual hour-long sessions.

Investigators also searched the therapy office, Wilkinson-Rivera and Rivera’s home and got email and cellphone records.

As they searched the records, they found a number of appointments which were allegedly billed for an hour, but they only spent a half-hour on the phone.

In addition, they allegedly discovered that there were online or phone therapy sessions that were billed as if they were in person. Emails between the couple showed them encouraging or directing employees to use phone sessions to increase billing.

They also found the insurance was billed for appointments that were canceled or missed.

“(Text) messages from Cloreese Wilkinson-Rivera to Carlos Rivera show they wanted to make as much money as possible after Cloreese Wilkinson-Rivera complains about working 50 hours and making little money in 2016,” according to court documents.

Phantom sessions

The bulk of the alleged fraud, more than $466,000, were for “phantom sessions.”

One of the examples listed was for a family of five people who were billed $23,000 for sessions that allegedly didn’t happened. One of the parents said she didn’t take her children to appointments during work hours for weekly sessions in the summer.

“The calendar entries show 417 of these sessions were phantom sessions or sessions that did not occur,” according to the affidavit.

In addition to the false bills, the couple also applied for health benefits from Medicaid for each other and each of their children between 2016 and 2019.

Fancy cars and house

The couple is accused of funneling the fraudulent payments into making car and mortgage payments.

While their West Richland home is now valued at more than $1 million, according to the Benton County Assessor’s Office, they paid $270,000 when they bought it in 2014.

According to court documents, they spent $112,000 on mortgage payments and $137,000 in car payments.

Among the car payments, there were five luxury cars they were paying for, including a 2004 Lamborghini Gallardo, a 2001 Ferrari Modena and a 1996 Ferrari.

Each of the cars can sell for between $80,000 and more than $100,000, according to CarFax.