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Colorado to receive over $1M in Medicaid fraud settlement with optical lens company

MM Curator summary

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: A national lens maker is paying up over kickback allegations in 35 states.

 
 

Colorado Attorney General Attorney General Phil Weiser has announced that Colorado will receive more than $1 million after an optical lens company paid providers kickbacks to refer patients to the company, resulting in the submission of false claims to the Colorado Medicaid program. In the settlement, Essilor, a company that manufactures, markets and distributes optical lenses and equipment used to produce optical lenses, agreed to pay 35 states a total of $22 million plus interest.

 
 

Clipped from: https://www.thechronicle-news.com/2022/09/14/colorado-to-receive-over-1m-in-medicaid-fraud-settlement-with-optical-lens-company/

 
 

Colorado to receive over $1 million in Medicaid fraud settlement with optical lens company

Sept. 8, 2022 – Attorney General Phil Weiser today announced that Colorado will receive more than $1 million after an optical lens company paid providers kickbacks to refer patients to the company, resulting in the submission of false claims to the Colorado Medicaid program.

In the settlement, Essilor, a company that manufactures, markets, and distributes optical lenses and equipment used to produce optical lenses, agreed to pay 35 states a total of $22 million plus interest.

“Kickbacks like those Essilor offered can harm consumers by leaving them with products that are not in their best interest. In this case, the kickbacks affected some of the most vulnerable Coloradans,” Weiser said. “Our office will continue to hold accountable companies that use such underhanded tactics to defraud the state’s Medicaid program.”

The settlement resolves allegations that between Jan. 1, 2011, and Dec. 31, 2016, Essilor knowingly and willfully offered to pay or paid eye care providers, such as optometrists and ophthalmologists, to purchase Essilor products for their patients, including Medicaid beneficiaries. Essilor’s conduct violated the Federal and Colorado’s False Claims Statute and resulted in the submission of false claims to the Colorado Medicaid program.

As part of the settlement, Colorado will receive $1,096,985.36 in restitution and other recoveries.

This settlement arises from two whistleblower lawsuits filed in the United States District Court for the Northern District of Texas and the Eastern District of Pennsylvania. A team from the National Association of Medicaid Fraud Control Units participated in the settlement negotiations on behalf of the states. The team included representatives from the offices of the Attorneys General for the states of California, Colorado, Indiana, Pennsylvania, and Texas.

The Attorney General’s Medicaid Fraud Control Unit is dedicated to protecting the integrity of the system that provides healthcare to the most vulnerable Coloradans. It accomplishes this through the investigation and prosecution of Medicaid provider fraud as well as the investigation and prosecution of the abuse and neglect of Medicaid clients in non-institutional settings as well as the abuse and neglect of patients in institutions that receive Medicaid dollars. To report potential Medicaid fraud, click here or call (720) 508-6696.

 
 

From <https://coag.gov/press-releases/9-8-22/>

 
 

 
 

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FWA- U.S. Attorney Settles Fraud Lawsuit Against Non-Profit For Inflating Medicaid Reimbursements By Falsely Reporting Millions In Costs

MM Curator summary

[MM Curator Summary]: Henry Coley used his “non profit” for Medicaid I/DD members to funnel cash to family members and his other businesses.

 
 

 
 

 
 

Maranatha Human Services Agrees to Cease Operations and Will Pay $850,000

Damian Williams, the United States Attorney for the Southern District of New York, and Scott Lampert, the Special Agent in Charge of the New York Office of the U.S. Department of Health and Human Services, Office of Inspector General (“HHS-OIG”), announced that the United States has settled civil fraud claims against Maranatha Human Services, Inc. (“MARANATHA”) for falsely claiming that millions of dollars expended to benefit for-profit ventures owned and controlled by MARANATHA and its founder HENRY ALFONSO COLEY (“COLEY”), as well as payments to cover COLEY’s personal expenses and excessive payments to COLEY’s family members, were reasonable and necessary costs in connection with MARANATHA’s provision of Medicaid-funded services to individuals with developmental disabilities.  MARANATHA is a non-profit organization based in Poughkeepsie, New York; COLEY founded MARANATHA in 1988 and served as its chief executive officer until last year. 

Specifically, the Government’s complaint, which was filed in November 2021, alleges that MARANATHA, with its board’s approval, funded for-profit companies operated by COLEY; paid excessive salaries and consulting fees to COLEY’s family members, often in exchange for little to no work; and paid for tens of thousands of dollars of COLEY’s personal expenses.  The Government further alleges that, from 2010 to 2019, COLEY and MARANATHA submitted to the State of New York cost reports that falsely claimed millions of dollars of these expenses as “allowable” costs, which fraudulently inflated MARANATHA’s Medicaid reimbursement rates and resulted in MARANATHA receiving millions of dollars in Medicaid funds to which it was not entitled.

U.S. Attorney Damian Williams said:  “For a decade, Henry Alfonso Coley and Maranatha defrauded Medicaid by submitting reports that fraudulently claimed as allowable expenses millions of dollars spent on for-profit companies owned by them, excessive salaries and fees for Coley’s family members, and Coley’s personal expenses.  These expenses were not related to providing care or assistance to the individuals with developmental disabilities who Maranatha was meant to serve.  Now Coley and Maranatha have each agreed to pay damages, Coley has been barred from working for any entity that bills federal healthcare programs, and Maranatha will close its doors.”

HHS-OIG Special Agent in Charge Scott Lampert said:  “It is incumbent upon the recipient of Medicaid funds to ensure that costs reported for reimbursement are accurate and in accordance with the program’s regulations; this is a steadfast requirement of participating in the Medicaid program.  The use of federal dollars for unallowable expenses diverts much-needed resources meant to support health care services for vulnerable individuals.  Putting a stop to such activity, through collaboration with our law enforcement partners, is a prime objective of HHS-OIG.”

Under the settlement approved yesterday by U.S. District Judge Kenneth M. Karas, MARANATHA agrees to cease operations after transitioning the operation of its programs to other providers under the supervision of the governing state regulatory agency.  MARANATHA will also pay $340,000 to the United States and has admitted and accepted responsibility for conduct alleged by the Government in its complaint as further described below.  In addition, MARANATHA has agreed to pay $510,000 to the State of New York to resolve the State’s claims, for a total recovery of $850,000.  The settlement amount is based on the Office’s assessment of MARANATHA’s ability to pay based on the financial information it provided and its commitment to cease operations.  The United States previously resolved the claims against COLEY through a settlement approved by Judge Karas on November 17, 2021.  In addition to paying damages to the United States and the State of New York, COLEY was barred from working for any entity that bills federal healthcare programs; he also entered into a Voluntary Exclusion Agreement with HHS-OIG, which prohibits him from, among other things, billing Medicaid and other federal healthcare programs for 15 years.

According to the Government’s complaint, from 2010 through 2019:

MARANATHA was required to submit cost reports, called Consolidated Financial Reports (“CFRs”), to the State of New York each year, specifying the reasonable and necessary costs MARANATHA incurred in providing services for its Medicaid-funded programs.  These costs were to be reported as “allowable” costs.  MARANATHA was required separately to report its other, “non-allowable” costs; “non-allowable” costs include costs unrelated to its Medicaid-funded programs, as well as any unreasonable or unnecessary costs. 

With its board’s approval, MARANATHA funded for-profit companies operated by COLEY and owned by COLEY or MARANATHA, as well as various unincorporated pet projects started by COLEY.  One of the chief purposes of these ventures was to serve as vehicles to funnel money to COLEY’s daughter, as well as others associated with COLEY, whom MARANATHA paid for work they purportedly did to support these ventures and projects.  Over the course of a decade, not one of these ventures ever launched a product or service or earned a single dollar in revenue.  COLEY and MARANATHA hired COLEY’s family members as employees and consultants, some in connection with these for-profit ventures, and others in connection with MARANATHA’s Medicaid-funded services.  COLEY and MARANATHA paid excessive salaries and consulting fees to COLEY’s family members, often in return for little to no work.  MARANATHA also paid for tens of thousands of dollars of COLEY’s personal expenses, including more than $34,000 for personal training sessions at a gym.

COLEY and MARANATHA knowingly submitted CFRs annually to the State of New York fraudulently reporting these expenses—totaling millions of dollars—as “allowable” costs.  On each CFR, COLEY falsely certified to the completeness and accuracy of the report.  COLEY and MARANATHA knew that the State of New York relied on providers’ CFRs when setting provider-specific reimbursement rates for certain Medicaid-funded programs, including MARANATHA’s largest Medicaid-funded program.  As a result of COLEY’s and MARANATHA’s falsely inflated cost reports, the State of New York awarded MARANATHA a higher reimbursement rate and MARANATHA received millions of dollars in Medicaid funds to which it was not entitled.

As part of the settlement, MARANATHA admits, acknowledges, and accepts responsibility for the following conduct:

  • COLEY made a presentation to MARANATHA’s board of directors acknowledging that “[i]t was always the plan for Maranatha to use government funds as a launching pad to create private enterprise that would enable it to not be dependent on [the] government while at the same time fulfilling its function” consistent with its mission.
  • MARANATHA knew of the requirement to distinguish “allowable costs” from “non-allowable costs” in its CFRs.
  • MARANATHA knew that the allowable costs reported in its CFRs are used by the New York State Department of Health, in part, to determine MARANTHA’s reimbursement rates for the provision of Medicaid services.
  • In each CFR that MARANATHA submitted from 2010 to 2019 (the “Covered Period”), MARANATHA’s CEO, COLEY, certified that (i) the “information furnished in this report . . . is in accordance with the instructions and is true and correct to the best of my knowledge”; and (ii) the statement attached to the CFR “fully and accurately represents all reportable income and expenditures made for services performed in accordance with the provision of the Mental Hygiene Law and approved budgets.”
  • Throughout the Covered Period, MARANATHA submitted CFRs every year that reported as “allowable costs” amounts expended not for MARANTHA’s provision of Medicaid-funded services but instead to pursue certain for-profit business ventures.
  • In particular, MARANATHA submitted CFRs reporting as “allowable costs” costs expended to benefit certain entities owned and/or operated by COLEY or MARANATHA that did not provide Medicaid-funded services (the “Non-Medicaid Ventures”).  
  • MARANATHA’s board, which approved MARANATHA funding these Non-Medicaid Ventures, was briefed on them by COLEY.
  • MARANATHA paid COLEY’s family members to perform work related to the Non-Medicaid Ventures.  For example, since 2010, MARANATHA paid COLEY’s daughter more than $300,000.  Though much of her time was spent on work related to the Non-Medicaid Ventures, MARANATHA reported her full compensation as an “allowable cost” in the CFRs.
  • Since 2010, MARANATHA paid COLEY more than $2 million in salary and benefits, and MARANTHA claimed the full amount of that compensation as “allowable costs” on its CFRs. However, COLEY devoted much of his time to working on the Non-Medicaid Ventures.
  • MARANATHA also paid for certain of COLEY’s personal expenses, including more than $34,000 spent on personal training sessions, as well as holiday gifts and jewelry.  MARANATHA reported these expenses as “allowable costs” in its CFRs.

This lawsuit originated as a whistleblower lawsuit filed under seal pursuant to the False Claims Act.

Mr. Williams praised the outstanding investigative work of HHS-OIG, and he thanked the Medicaid Fraud Control Unit at the New York State Attorney General’s Office for its extensive collaboration in the investigation.

The case is being handled by the Office’s Civil Frauds Unit.  Assistant U.S. Attorney Jacob Lillywhite is in charge of the case.

 
 

Clipped from: https://www.justice.gov/usao-sdny/pr/us-attorney-settles-fraud-lawsuit-against-non-profit-inflating-medicaid-reimbursements

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FWA- Philipsburg Woman Sentenced for Social Security, Medicaid Fraud

MM Curator summary

[MM Curator Summary]: Mr. Pearson lied about hubbs moving out in order to keep receiving SSI and Medicaid benefits for over 10 years that she wasn’t supposed to.

 
 

 
 

 
 

 
 

56-year-old Virginia Pearson of Philipsburg will be spending a year and a day in prison after admitting in Missoula Federal Justice Court on Wednesday that she lied for over 10 years to receive Social Security and Medicaid benefits that she was not eligible to receive.

Federal court records indicate that Pearson knew that she was obligated to report her income and other resources, but instead lied for over 10 years to receive over $101,000 in Social Security benefits, over $23,000 from the Montana Department of Health and Human Services, and over $18,000 from Medicaid.

Pearson applied for Social Security benefits in 2006 and was approved to receive the benefits starting in 2008.

Pearson is married to Doyle Pearson, but falsely claimed that he had moved out of their home, thus increasing her benefits significantly. She received nine cost of living adjustments and two ‘change in payment’ letters which explicitly detailed her obligations to report all her income and resources.

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An investigation revealed that her statements were false and that she and her husband lived together and co-owned the house.

Montana’s U.S. Attorney Jesse Laslovich said Pearson was sentenced to one year and a day in prison and ordered to pay restitution of $142,542.

U.S. District Court Judge Donald Molloy presided over the case and remanded Pearson into custody.

Inspector General for the Social Security Administration, Gail S. Ennis, said:

“This sentence holds Ms. Pearson accountable for defrauding government programs. As part of her scheme, she abused the Supplemental Security Income program, the needs-based safety net for the most vulnerable among us by falsifying her true circumstances and causing SSA to improperly pay her over $101,000. My office will continue to pursue those who exploit SSA programs for personal gain. I thank our law enforcement partners for their support in this investigation and the U.S. Attorney’s Office for prosecuting this case.”

Assistant U.S. Attorney Karla Painter prosecuted the case.

 
 

Clipped from: https://newstalkkgvo.com/philipsburg-woman-sentenced-for-social-security-medicaid-fraud/

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FWA- Medicaid Recipients Agree to Pay $130,000 to Resolve False Claims Act Allegations of Health Care Benefit Fraud

MM Curator summary

[MM Curator Summary]: Mr and Mrs Kamboj had lots of assets and a gigantic house- but still got $70k in Medicaid benefits. Just like the state auditor said was happening and when lefties shot him down.

 
 

 
 

 
 

Jackson, Miss. – Darren J. LaMarca, United States Attorney for the Southern District of Mississippi, announced today that Manpreet Kamboj and Gurdev Kamboj (aka David Singh) have agreed to pay $130,000 to resolve allegations that they knowingly falsified income to unlawfully create eligibility for Mississippi Medicaid health care benefits for their dependents.

The Medicaid Program is a state and federally funded health benefit program intended to assist low-income individuals and families. The Mississippi Division of Medicaid (MDOM) is the single state agency responsible for administering health care benefits for eligible, low-income individuals in Mississippi.

Despite Medicaid’s low-income requirement, the United States contends that Manpreet Kamboj and Gurdev Kamboj collectively owned and/or were associated with 48 convenience store/gas stations located in Mississippi and Louisiana.  The Kambojs also own a five-bedroom 7,850 square foot home located in Madison, Mississippi, most recently valued at 1.3 million dollars. 

According to the United States, the Kambojs falsely represented on various Mississippi Medicaid health care benefit applications and renewals that one of them was unemployed and that the household derived income from one convenience store/gas station.  As such, the United States alleges that from August 29, 2011, to February 28, 2022, the Kambojs caused the MDOM to pay over $70,000 in health care coverage benefits to which they were not entitled.  

“The Medicaid Program is intended to provide access to quality health coverage for vulnerable Mississippians,” said U.S. Attorney Darren LaMarca.  “Our office will continue to pursue those individuals who unlawfully deplete valuable resources allocated for Medicaid eligible individuals and families.” 

The False Claims Act claims settled are allegations only, and there has been no determination of liability.  This case was investigated by the U.S. Department of Health and Human Services, Office of the Inspector General. 

 
 

Clipped from: https://www.justice.gov/usao-sdms/pr/medicaid-recipients-agree-pay-130000-resolve-false-claims-act-allegations-health-care

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FWA- Alabama pill mill doctor’s sister said she obeyed him due to Nigerian cultural norms; sentences upheld

[MM Curator Summary]: Apparently the patriarchy and toxic masculinity in Nigerian culture is not a sufficient defense against fraud charges in Alabama.

 
 

Judges on the U.S. Court of Appeals for the 11th Circuit upheld last week the 30-year sentence of an Alabama doctor who prescribed high numbers of opioids and fraudulently billed for allergy treatment.

A jury found Dr. Patrick Ifediba and his sister, Ngozi Justina Ozuligbo, guilty in 2019 on dozens of counts of health care fraud and controlled substances violations. U.S. District Court Judge David R. Proctor sentenced Ifediba to 30 years and Ozuligbo to three years in prison.

Ifediba challenged his conviction because the court barred evidence of his good care to other patients, failed to address wrongdoing by an alternate juror and incorrectly calculated the amount of unlawfully prescribed opioids, according to court documents.

Ifediba operated Care Complete Medical Clinic in Birmingham with his wife, Dr. Uchenna Ifediba. According to court documents, neither one specialized in pain care, but they prescribed high numbers of opioids such as oxycodone and fentanyl. About 85 percent of the patients at CCMC received opioid prescriptions, according to the U.S. Department of Justice.

“CCMC attracted patients who were willing to wait over three hours in a dirty, crowded waiting room to receive prescriptions for controlled substances,” appeals court judges wrote in the opinion. “The clinic stayed open until 10:00 PM to accommodate them.”

Authorities in the case estimated Ifediba unlawfully prescribed between 30,000 and 90,000 kilograms of drugs. The doctor said the true estimate should have been between 1,000 and 3,000 kilograms, which would have reduced his sentence. Judges on the appeals court upheld the long sentence and agreed with the way federal investigators calculated the volume of drugs.

In addition to the opioid prescriptions, investigators also found that Ifediba performed costly allergy tests on almost all patients with insurance. He also prescribed expensive immunotherapy treatments for many patients, including some who tested negative for allergies.

The allergy tests cost more than $500 per patient and shots cost $2,660, according to the court opinion. Staff at Blue Cross Blue Shield of Alabama initially flagged the high numbers of allergy treatments and notified federal authorities, according to court documents. When the insurer moved to audit the clinic, staff members changed documents and test results to support treatment.

During the trial, an alternate juror violated court instructions and did online research about the case and discussed it with coworkers, according to the opinion. The juror was dismissed, but Ifediba argued more should have been done to determine whether the alternate discussed findings with other jurors.

Ozuligbo also challenged her conviction, arguing that she should have been allowed to present evidence of Nigerian cultural norms that required her to obey her brother. She worked as a nurse with a company that administered allergy tests and treatment but remained on site at CCMC.

“There was more than sufficient evidence to demonstrate that CCMC defrauded insurers through an allergy fraud scheme,” judges wrote in the opinion. “The only question is whether Ozuligbo was a knowing and voluntary participant in the conspiracy.”

Although Ozuligbo said she was just an employee, medical records showed she had signed and recorded negative allergy tests and then administered treatments the patients didn’t need.

Ifediba was convicted on 14 counts of unlawful distribution of controlled substances, 10 counts of health care fraud and one count of conspiracy to commit money laundering, among other charges. Ozuligbo was convicted of nine counts of health care fraud and one count of conspiracy to commit money laundering, plus some additional charges.

U.S. Attorney for the Northern District of Alabama Prim F. Escalona made a statement in 2020 when Ifediba was sentenced.

“Physicians who choose to deal drugs while hiding behind their white coats are no different than drug dealers who hide in alleys,” Escalona said. “The greed of Dr. Ifediba contributed to the ongoing opioid crisis that is plaguing our communities.

 
 

Clipped from: https://www.msn.com/en-us/news/crime/alabama-pill-mill-doctor-e2-80-99s-sister-said-she-obeyed-him-due-to-nigerian-cultural-norms-sentences-upheld/ar-AA11eO80

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FWA- California suspends Medicaid payments to Borrego Health for 2nd time in 2 years

[MM Curator Summary]: If it walks like a duck..

 
 

For the second time in two years, California health officials are suspending all Medicaid payments to federally qualified health center Borrego Health for “continued and unresolved inappropriate billings,” the San Diego Union-Tribune reported Aug. 30.

The California Department of Health Care Services’ decision comes after state and federal authorities launched a criminal investigation into millions of dollars of alleged improper billings, excessive salaries and above-market rent payments at Borrego Spring-based Borrego Health, according to the report. It also comes after Borrego Community Healthcare Foundation sued several past board members, executives and contractors over allegations of racketeering, fraud, nepotism, excessive compensation and self-dealing.

Borrego Health’s Medicaid reimbursements were first suspended in December 2020 after state and federal agents raided Borrego Health locations, seizing computers, taking medical records and interviewing employees. 

Regulators agreed to reinstate Medicaid reimbursements for medical services in early 2021, but not for dental work, which remains the focus of the criminal investigation, according to the report. The reinstatement came after Borrego Health agreed to an independent monitor and other conditions. 

In an Aug. 19 letter obtained by the San Diego Union-Tribune, state health officials said they would withdraw all Medicaid reimbursements by Sept. 29 because of Borrego Health’s alleged failure to meet its settlement obligations.  

A Borrego Health spokesperson told the San Diego Union-Tribune the decision was unwarranted and unexpected and will “significantly and abruptly reduce access to care for thousands of at-risk Californians.”

 
 

 
 

Clipped from: https://www.beckershospitalreview.com/finance/california-suspends-medicaid-payments-to-borrego-health-for-2nd-time-in-2-years.html

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FWA- Southwest Idaho woman gets jail, fines for Medicaid fraud

[MM Curator Summary]: Pretty pedestrian bogus claims fraud here. Nothing to see except another half a million or so of the taxes taken out of your W-2 going up in smoke.

 
 

 
 

BOISE, Idaho

A southwestern Idaho woman who pleaded guilty to defrauding the Idaho Department of Health and Welfare’s Medicaid program by falsely claiming services to participants with developmental disabilities has been sentenced to 180 days in the Ada County Jail and must repay more than $146,000 in criminal restitution.

Attorney General Lawrence Wasden announced Monday that 58-year-old Janna Lyn Miller of Kuna received the sentence Thursday in 4th District Court.

District Court Judge Samuel Hoagland also ordered Miller to pay $83,000 in criminal restitution as well as $2,000 in court costs. Officials recovered $64,000 in fraudulent payments before sentencing.

Miller also received a five-year suspended sentence with five years of probation. She will have to spend a minimum one year in state prison if she violates her probation.

In addition to the criminal restitution, Miller owes the state more than $234,000 in additional overpayments and related penalties. All told, she is responsible for paying more than $375,000 related to her company’s actions.

The attorney general’s office said that Miller owned and operated Inclusion, Inc., a Meridian-based company that provided home health, supervised employment, mental health counseling and social support services to Idaho Medicaid participants with developmental disabilities.

Besides the main office in Meridian, the company also had offices in Sandpoint, Coeur d’Alene and Twin Falls.

The attorney general’s office said Miller wrongfully obtained Medicaid funds by making false representations or directing workers to make false representations regarding services provided.

Miller’s prosecution resulted from a coordinated effort by the U.S. Department of Health and Welfare’s Medicaid Program Integrity Unit, the Idaho Branch of the Office of the Inspector General of the U.S. Department of Health and Human Services, and the state attorney general’s Medicaid Fraud Control Unit.

This story was originally published August 30, 2022 5:12 AM.

Clipped from: https://www.newsobserver.com/news/article265057249.html

News


 

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California county, three health systems pay $70.7 million for Medicaid fraud

[MM Curator Summary]: Who said county plans have to miss out on all the fraud fun? Sorry, I mean “alleged” fraud fun.

 
 

 
 

Justice Department: Federal health care money not a “blank check” to misuse.

 
 

The health system operated by Ventura County, California, and three health care providers will pay $70.7 million to settle allegations they defrauded California’s expanded Medicaid program.

The U.S. Department of Justice (DOJ) and the California Attorney General’s Office announced the settlement for false claims from January 2014 to May 2015. The time coincides with California’s expansion of its Medicaid program, known as Medi-Cal, to cover previously uninsured adults with incomes up to 133% of the federal poverty level.

That expansion was allowed under the federal Affordable Care Act and was reimbursed by the federal government for the first three years. If county organized health systems (COHSs) did not spend at least 85% of the money they received on allowed medical expenses, they were required to reimburse the state of California, which would return the money to the federal government, according to DOJ.

The settlement resolves allegations that the county and three health care systems knowingly submitted false claims to Medi-Cal for allowable expenses, according to DOJ. The billed services were duplicative of those already provided, and some services were never provided, Acting U.S. Attorney Stephanie S. Christensen said in a news release.

“Federal health care funds are not intended to serve as a blank check,” Principal Deputy Assistant Attorney General Brian M. Boynton said in a news release. Boynton serves as head of DOJ’s Civil Division.

 
 

Clipped from: https://www.medicaleconomics.com/view/california-county-three-health-systems-pay-70-7-million-for-medicaid-fraud

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TX- Two charged in $6M pediatric dental Medicaid fraud/kickback scheme

[MM Curator Summary]: Pretty large for a dental fraud. Its like a kick in the teeth for Medicaid bennies waiting on dental services.

 
 

 
 

HOUSTON – An operator and manager at a dental clinic have been charged for their roles in a health care fraud scheme involving $6 million in claims to Medicaid, announced U.S. Attorney Jennifer B. Lowery.

Authorities took Ifeanyi Ndubisi Ozoh, 51, Houston, into custody today. He is expected to make his initial appearance tomorrow before U.S. Magistrate Judge Sam Sheldon at 2 p.m. Also charged is Rene Fernandez Gaviola, 65, also of Houston. He had been previously arrested on similar charges Aug. 1. He is expected to appear on the new charges in the indictment in the near future.

On Aug. 16, a federal grand jury returned the 13-count indictment which was unsealed upon Ozoh’s arrest today.

According to the charges, Gaviola was the operator, while Ozoh was the manager of Floss Family Dental Care clinic located in Houston.   

The indictment alleges Gaviola and other employees submitted false and fraudulent claims to Medicaid for dental services such as cavity fillings that were never provided as billed. Gaviola and Ozoh also allegedly paid kickbacks to marketers and caregivers of children Medicare insures to bring them to Floss for dental services.

Gaviola also employed at least one individual to practice pediatric dentistry without a license and billed Medicaid for their services, according to the charges.

The indictment further alleges Gaviola laundered Medicaid monies from the Floss business bank account to his personal bank account in several transactions exceeding $100,000.

From 2019 to 2021, the dental company allegedly billed Medicaid for nearly $6.9 million for which Medicaid paid approximately $4.9 million. Many of the dental services were not provided or that unlicensed and non-enrolled individuals had administered.

If convicted,  Ozoh and Gaviola face up to five years in federal for conspiracy to pay and receive kickbacks. Gaviola also faces up to 10 years for conspiracy to commit health care fraud and each count of health care fraud and money laundering. All charges also carry a possible $250,000 maximum fine.

The FBI, Texas Attorney General’s Medicaid Fraud Control Unit and the Department of Health and Human Services – Office of Inspector General conducted the investigation with assistance of Customs and Border Protection. Special Assistant U.S. Attorney Kathryn Olson is prosecuting the case.

An indictment is a formal accusation of criminal conduct, not evidence.
A defendant is presumed innocent unless convicted through due process of law.

 
 

Clipped from: https://www.justice.gov/usao-sdtx/pr/two-charged-6m-pediatric-dental-medicaid-fraudkickback-scheme

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Lawrence woman to pay $7K+ for fraudulent Medicaid claims

[MM Curator Summary]: She gave her son her login info so he could fill out fake timesheets for her saying that she was caring for him. Not making this up.

 
 

 
 

LAWRENCE, Kan. (WIBW) – A Lawrence woman will pay more than $7,000 to the AG’s Office and the state Medicaid program after she claimed she was caring for her beneficiary son while she was working as a nurse in an ER instead to fraudulently gather benefits.

Kansas Attorney General Derek Schmidt says on Tuesday, Aug. 23, Terri Lisa Schwager, 56, of Lawrence was ordered to repay the Kansas Medicaid program more than $5,000 for filing false billing claims.

AG Schmidt said Schwager agreed to a consent judgment approved by Douglas Co. District Judge Mark Simpson on Aug. 19. He said Schwager agreed to repay the program a total of $5,085.62, as well as $5,085.62 in fines and $2,700.35 for investigative costs incurred by the Medicaid Fraud and Abuse Division of the AG’s office.

Schmidt noted that investigators found Schwager served as a personal care attendant for her adult son, who is a Medicaid beneficiary. The investigation found between Jan. 1, 2018, and March 31, 2022, she had provided her confidential user information to her son who logged into the app 91 times to indicate his mother was giving him the help he needed.

However, investigators found that Schwager was instead working as an emergency room nurse in Olathe at the time the claims were logged.

Schmidt noted that the case was litigated by Senior Assistant Attorney General Eve Kemple of his office.

 
 

Clipped from: https://www.wibw.com/2022/08/23/lawrence-woman-pay-7k-fraudulent-medicaid-claims/