FWA- South Plainfield health care provider ordered to repay $1 million in Medicaid overpayments

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[MM Curator Summary]: John stole $1M of your tax dollars and put kiddos at risk by not ensuring “providers” in his organization had basic background checks or licenses.



A South Plainfield man who works as a behavioral health provider has been ordered by the state to repay Medicaid more than $1 million for improperly billing the program.

John Gore, a licensed drug and alcohol counselor at Clear Conscience Counseling on Park Avenue in South Plainfield, also allowed behavioral assistants to provide services to minors in one-on-one settings without conducting criminal background checks on the staffers, an audit by the Office of the State Comptroller (OSC) found.

The audit determined that Gore improperly billed and received Medicaid payments of $1.1 million.

The audit also found Gore failed to comply with state regulations in about a third of claims the State Comptroller’s office sampled.

The OSC also found Gore billed for unsubstantiated services, maintained inaccurate and incomplete records and failed to ensure that his providers had current and valid drivers’ licenses before allowing them to provide services to Medicaid patients, according to a news release from the agency.

Other deficiencies discovered in the audit include Gore assigned cases to behavioral assistants without confirming they had the required professional licenses. The audit found that six did not.

Gore also failed to ensure that behavioral assistants had the required training certifications and the audit discovered 24 did not, according to the agency.

As a result of the audit’s findings, OSC has urged the New Jersey Division of Medicaid Assistance and Health Services (DMAHS), part of the Department of Human Services, to issue a rule requiring intensive in-community (IIC) providers to undergo fingerprint background checks before being allowed to treat children and young adults.

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IIC providers are now required to obtain criminal background checks of behavioral assistants, but there is no government oversight to enforce that requirement and no requirement for a fingerprint check, according to the OSC.

“It’s standard practice for teachers, doctors, coaches, and many others who work with children to undergo fingerprint checks. Children who are in these Medicaid-funded community programs are entitled to the same protection,” Josh Lichtblau, director of OSC’s Medicaid Fraud Division, said in the release.

In November 2021, the State Comptroller’s office notified DMAHS about flaws in the regulations and the risks they posed to children.

Almost a year later, in September 2022, DMAHS told providers that they should contact the state’s Children’s System of Care to initiate fingerprint background checks, but it left the responsibility for compliance on the provider.

DMAHS proposed a new rule in January that did not address the fingerprint requirement and state oversight.

“Our findings are serious. When providers fail to ensure that employees have clean criminal backgrounds, they’re placing vulnerable children in potentially unsafe circumstances,” said Lichtblau. “The state should work quickly to close this gap in oversight.”

Email: srussell@gannettnj.com

Suzanne Russell is a breaking news reporter for MyCentralJersey.com covering crime, courts and other mayhem. To get unlimited access, please subscribe or activate your digital account today.


From <https://www.mycentraljersey.com/story/news/health/2023/02/23/nj-health-care-john-gore-medicaid-insurance/69936127007/>