FWA (NY)- Berks personal care agency accused of getting $488,000 in Medicaid-billing scheme


MM Curator summary

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[MM Curator Summary]: Mata stole $488k with bogus home care claims.



Clipped from: https://www.readingeagle.com/2023/04/06/berks-personal-care-agency-accused-of-getting-488000-in-medicaid-billing-scheme/

Part of Our Family Home Care Agency is charged with claiming reimbursement for services that were never performed.


Berks personal care agency accused of getting $488,000 in Medicaid-billing scheme

State authorities have accused the owner of a Berks County company that provides nursing-home-level care to people in their residences of claiming nearly a half-million dollars in Medicaid reimbursement for services that were never performed.

Based on a recommendation from a state grand jury, Gavin Mata and his company, Part of Our Family Home Care Agency, 20 N. Front St., Bally, were charged this week with Medicaid fraud, theft by deception and tampering with records, state Attorney General Michelle Henry announced Wednesday.

Mata, 36, of Bronx, N.Y., is also charged with perjury and four counts of identity theft.

Between January 2020 and April 2022, the Medical Assistance program paid Part of Our Family $488,349 for services that were never performed, investigators said.

Some of the reported clients had never signed up for or received care from Part of Our Family, and agency employees were not aware Mata had reported these services, investigators said.

“Medicaid is a lifeline to essential services for low-income Pennsylvanians, and this agency exploited the system to defraud and steal for personal interests,” Henry said. “Criminals who defraud Medicaid are targeting our most vulnerable Pennsylvanians, who trust their caregivers to look out for them, and all hard-working Pennsylvania taxpayers.”

Mata remained free to await a hearing following arraignment Tuesday before Senior District Judge Gloria W. Stitzel in Boyertown.

Mata did not immediately respond to a request for comment.

According to investigators:

Mata applied to the state Department of Human Service in August 2019 as president and sole owner of Part of Our Family to enroll as a provider of personal assistance services to Medical Assistance recipients who meet the criteria.

Mata began billing for those services purportedly provided by his employees.

About a year later, the state attorney general’s Medicaid Fraud Control Section received a referral from one of the managed care organizations that is contracted by the state to establish a provider network for Medical Assistance recipients.

It was reported at that time that there were complaints that Part of Our Family billed for services that were not provided to two recipients. The managed care agency found it suspicious that all the work shifts for which Part of Our Family claimed to have rendered to those clients had been manually entered into the electronic verification exchange rather than entered by the workers.

Through the electronic exchange, personal care workers are able to clock in and clock out and get paid by their employees. This is usually done via a mobile app or through a telephone call-in system.

The exchange used by Part of Our Family allows personal assistance workers and administrators to log hours that are ultimately billed to the approved managed care organization.

Because the shifts for services were entered by administrative staff of Part of Our Family and not directly by the workers, the managed care agency requested time sheets substantiating that the billed hours were provided to the Medical Assistance recipients.

In response, Part of Our Family provided computer-generated time sheets that contained only manager’s signatures. They lacked signatures of the client and the worker.

It was determined that part of Our Family was paid a total of $8,615 for services that were not provided to those two recipients.

As part of the grand jury’s investigation, subpoenas were served on Part of Our Family directing the agency to provide Medical Assistance recipient files along with time sheets and payroll information, employee files and related documents.

Part of Our Family provided only minimal information, with many of the files consisting of a calendar printout of the hours that were submitted through the electronic exchange.

In addition, the number of employee files provided by the agency was less than the number of employees listed on the agency’s payroll and/or listed as having worked for Part of Our Family under the exchange. Most of the files lacked basic information such as employee applications, clearances and tax information.

Special Agent Nicole Tomlinson interviewed numerous Medical Assistance recipients whom Part of Our Family claimed to have served.

Some of those Medical Assistance recipients said they declined Part of Our Family’s offer via telephone conversation to provide service and were surprised to see documentation that Part of Our Family had billed for services rendered to them.

Tomlinson also tracked down some former workers, two of whom testified before the grand jury. One of the workers was shown documents that Part of Our Family had showing her working at two recipients’ homes at the same time. The worker testified that she may not recall exactly which client she worked for on a given date but confirmed she could not have been in two places at once.

Records revealed that Part of Our Family billed for the rendering of 3,900 hours of personal services under her name but only paid her for 3,442 hours through payroll.

In all, officials documented that Part of Our Family received over $488,349 from Medical Assistance for nonexistent services.