Tag: Fraud

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[MM Curator Summary]: A very large member fraud involved family members switching roles back and forth between “patients” and “care givers.”

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.

MINNEAPOLIS — A Minnesota woman has entered guilty pleas in a case stemming from a scheme that defrauded a state medical assistance program out of more than $860,000, Attorney General Keith Ellison announced Tuesday, Jan. 18.

The Medicaid Fraud Unit of the Minnesota Attorney General’s Office in 2021 charged Trenea Deshawn Davis and seven others, mostly family members, with running a five-year-long benefits scam on Minnesota’s Medicaid program.

Prosecutors said Davis recruited family members and friends to feign and exaggerate medical conditions in order to qualify for personal care assistants. They then falsely reported care services and split the money, according to the attorney general.

Davis, who as a part of her plea agreement admitted to running the ring, reported working as a care assistant for more than 7,000 hours between December 2014 and May 2018 before taking on the role of patient and reporting 12 hours of care a day.

Davis pleaded guilty to five counts of aiding and abetting theft by swindle and will be sentenced Feb. 15. Of her seven co-conspirators, six have pleaded guilty, according to the Attorney General’s Office.

Clipped from: https://www.duluthnewstribune.com/news/minnesota/minnesota-woman-admits-toto-860k-medicaid-fraud

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[ MM Curator Summary]: Academy Health must pay back hundreds of thousands of dollars AND stop operations.

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.

OHIO — The U.S. Department of Justice announced it has reached a settlement with Ohio-based Academy Health Care Services after the organization agreed to close and pay $500,000. 

What You Need To Know

• The U.S. Department of Justice reached a settlement with Dayton-based Academy Health Care Service under the False Claims Act
  

• Half of the $500,000 will be paid toward restitution
  

• The settlement stipulated that Academy must cease operations by June 30
  

• The DOJ said that Academy’s billing practices routinely caused Ohio Medicaid to pay at a higher level of reimbursement than warranted
  

The Department of Justice said that Academy Health Care Service settled under the False Claims Act. The company agreed to cease operations no later than June 30. 

The DOJ said that Academy Health Care Service “billing practices routinely caused Ohio Medicaid to pay at a higher level of reimbursement than warranted by the services provided as well as the setting in which the services were provided.”

The DOJ added that “Academy billed for individual healthcare services when any services it actually provided were in group settings. Further, Academy nurses did not spend the time required with patients to receive reimbursement for individual services.”

The company’s website was no longer functional, as of Tuesday. In an archived version of the website, the company claimed it specializes in home health care and that ensured that patients receive prescribed medications on time, proper nutrition and help with grooming.

The DOJ said that Academy was based in Dayton and serviced patients in Ohio.

Half of the $500,000 settlement will be used toward restitution. 

Clipped from: https://spectrumnews1.com/oh/columbus/news/2022/01/04/company-accused-of-overbilling-ohio-medicaid-reaches-doj-settlement

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[ MM Curator Summary]: The Empower story gets deeper.

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.

LITTLE ROCK, Ark. – Arkansas Attorney General Leslie Rutledge announced Tuesday that Empower Healthcare Solutions, LLC will pay Medicaid almost $8 million in civil penalties and additional reconciliation payments.

According to Rutledge, the false claims settlement was based on a joint investigation that was initiated after questions were raised about how Empower was reporting expenses in 2020.

The Medicaid Fraud Control Unit found that Empower had improperly reported over $10 million dollars, officials said.

Empower maintains that the improper reporting was unintentional but did agree to modify its reporting and pay the state of Arkansas $1 million in civil penalties and costs, the attorney general’s office explained.

Officials said in addition to the $1 million Empower agreed to pay, the adjustments to its report of expenses in 2020 resulted in the company owing the Arkansas Medicaid Program more than $6 million dollars. The combined recovery from the settlement is $7,983,511.

“Over the past seven years, the Medicaid Fraud Control Unit has obtained 155 convictions and over $43 Million in monetary compensation for the people of Arkansas,” Rutledge said.

To report Medicaid fraud or false claims call the Medicaid fraud hotline at 866-810-0016.

Clipped from: https://www.kark.com/news/state-news/attorney-general-announces-multimillion-dollar-medicaid-fraud-settlement-with-empower-healthcare-solutions/

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[ MM Curator Summary]: A GA counselor stole more than $600,000 from Medicaid using fake documentation in her pediatric mental health practice.

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.

Attorney General Chris Carr announced that Brenda Copeland has pleaded guilty in Houston County Superior Court to two felony counts of Medicaid Fraud.

File Photo/MDJ

ATLANTA — Attorney General Chris Carr announced that Brenda Copeland has pleaded guilty in Houston County Superior Court to two felony counts of Medicaid Fraud. Superior Court Judge Edward D. Lukemire accepted the plea on Nov. 30 and sentenced the defendant to 10 years, including two years to be served in prison with the remainder on probation.

The court also ordered restitution to the Medicaid Care Management Organizations impacted, Wellcare and Peachstate, in the amount of $631,843.

“Georgia’s health care providers are an essential component of our Medicaid program, and we expect the best,” Carr said in a news release. “By violating public trust and stealing taxpayer dollars, Brenda Copeland harmed the very people in need of care — Georgia’s children and older and at-risk adults. This sentence sends a strong message that the state of Georgia will not tolerate this type of illegal and deceptive behavior.”

Copeland owned and operated The Counseling and Training Center in Warner Robins. Though she was not authorized to run a group practice, Copeland was enrolled as an individual practitioner to provide mental health services to children. In doing so, she submitted billing for upwards to 18 hours a day — including weekends, early mornings and late evenings — to cover for her non-credentialed staff, who also were not authorized to provide services.

Among the intentional lapses in her practice, Copeland enrolled Medicaid recipients in her program that were not properly diagnosed by a licensed clinical professional — a critical first step in authorizing treatment and billing claims for that recipient. Documentation attesting to such assessments was false.

This case was prosecuted by Assistant Attorney General Henry A. Hibbert of the Medicaid Fraud Division and was investigated and prepared by Investigator Johnny Brooks along with Investigator Ulecia Daniel, Investigator Melanie Mayone Sawdye and Intel Analyst Zwella Boyd.

Clipped from: https://www.henryherald.com/news/houston-county-counselor-pleads-guilty-in-medicaid-fraud-case/article_1264e66f-bf14-5dbb-ac07-1e43b31e6add.html

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[ MM Curator Summary]: 3 recent audits of the NY Medicaid program show significant preventable losses.

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.

(Photo: Getty Images)

ALBANY, N.Y. (NEWS10) – New York State Comptroller Thomas P. DiNapoli has released three reports that found more than $100 million in improper payments made by the Department of Health (DOH) for the Medicare buy-in program, maternity care, and drug and therapy claims. Nearly $400,000 in premiums may have been paid for deceased individuals.

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“The Medicaid program provides critical health care services to millions of New Yorkers but the program is dogged by oversight problems and payment errors,” said DiNapoli. “Over the years, we’ve uncovered billions of dollars of waste and abuse in the system. DOH should act on our recommendations to ensure significant unnecessary expenses and preventable mistakes don’t end up costing taxpayers.”

The New York State Medicaid program is administered by DOH and is a federal, state, and local government funded program that provides medical services to economically disadvantaged populations. As of March 2021, the program had about 7.3 million recipients and claim costs totaled more than $68 billion.

One audit found that Medicaid made $31.7 million in improper Medicare premium payments from January 1, 2015 through December 31, 2019. Medicaid also paid $372,716 in Medicare premiums for 282 individuals who were deceased. Auditors found Medicaid paid $23.6 million in premiums for individuals who were automatically added to the buy-in program with coverage beginning more than two years retroactively, despite limitations on this.

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The second audit examined Medicaid recipients who receive their services through managed care. DOH pays managed care organizations (MCOs) a monthly premium for each enrolled recipient and the MCOs pay for services their members require. MCOs can also receive a Supplemental Maternity Capitation Payment (SMCP) for prenatal and postpartum physician care and delivery costs. However, MCOs are not eligible to receive SMCPs for maternity cases that end in termination or a miscarriage.

Auditors found about $55 million in improper and questionable SMCPs to MCOs from August 1, 2015 to July 31, 2020. They found $29.1 million was paid without the required supporting data, $23.4 million was paid where the data or other evidence indicated the maternity case ended in termination or miscarriage, and $2.4 million was paid when the SMCP date of service preceded the birth by one to six months.

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A report released in October 2019 examined payments made for prescription drugs and therapy services. It found Medicaid paid $20.1 million for services that should have been paid by Medicare. A follow-up report found DOH made some progress in addressing these problems, however, auditors identified another $17.7 million in payments that should have been paid by Medicare.

You can read the full reports on the State Comptroller website.

Clipped from: https://www.mytwintiers.com/ny-news-2/nys-comptroller-department-of-health-paid-over-100m-in-improper-medicaid-payments/

MM Curator summary

[ MM Curator Summary]: 2 women who set up an entire shadow company solely for the purpose of defrauding Medicaid will get probation and have their prison sentences suspended.

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.

Las Vegas, NV – Nevada Attorney General Aaron D. Ford announced that Randi Jewel Lewis, 30, of Las Vegas, was sentenced in a Medicaid fraud case involving falsely billing for Medicaid services allegedly provided to Medicaid recipients.

Lewis pleaded guilty to one count of Medicaid Fraud and one count of Money Laundering. District Court Judge Jasmin Lilly-Spells sentenced Lewis to between 19 to 48 months in prison, suspended, and placed her on probation. Lewis was also ordered to pay more than $30,000 in restitution, penalties and costs.

“My office is committed to combatting Medicaid fraud to ensure the wellbeing of its recipients and to safeguard taxpayer resources,” said AG Ford. “Prosecutions of these types of crimes helps deter future crimes against the Medicaid system, and stop predatory fraudsters from gaming the system to their advantage.”

The investigation began after the Medicaid Fraud Control Unit (MFCU) received an allegation that Vegas Health LLC (Vegas Health) submitted false information to Medicaid. The investigation revealed that Lewis and her co-defendant, Shonna Nicole Marshall, formed a ghost company with the sole objective of fraudulently billing Medicaid.

Lewis and Marshall used Medicaid providers’ and recipients’ personal information without their knowledge or consent. Lewis and Marshall then transferred the fraudulently obtained funds into multiple bank accounts and to multiple associates in order to conceal the source of the funds. Marshall, who pleaded guilty to one count of Medicaid Fraud and twenty-six counts of Money Laundering, is scheduled to be sentenced in January for her role in the fraudulent scheme.

The MFCU investigates and prosecutes financial fraud by those providing healthcare services or goods to Medicaid patients. The MFCU also investigates and prosecutes instances of elder abuse or neglect. The Nevada MFCU receives 75% of its funding from the U.S. Department of Health and Human Services under a grant award. The remaining 25% is funded by the State of Nevada, MFCU. Persons convicted of Medicaid fraud may also be administratively excluded from future Medicaid and Medicare participation. Anyone wishing to report suspicions regarding any of these concerns may contact the MFCU at 702-486-3420 or 775-684-1100.

This case was investigated by the Attorney General’s Medicaid Fraud Control Unit and was prosecuted by Senior Deputy Attorney General Behnaz Salimian Molina.

The amended indictment for Randi Jewel Lewis is attached.

To file a complaint with the Office of the Nevada Attorney General, click here.

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Clipped from: https://ag.nv.gov/layouts/Page_Style_1.aspx?id=345188

[ MM Curator Summary] 2 NY NET dispatchers routed trips to a company owned by a person they colluded with to commit fraud.

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.

Damian Williams, United States Attorney for the Southern District of New York, Scott J. Lampert, Special Agent in Charge of the New York Regional Office of the U.S. Department of Health and Human Services, Office of the Inspector General (“HHS-OIG”), and Ricky J. Patel, Acting Special Agent in Charge of the New York Field Office of the Homeland Security Investigations (“HSI”), announced the unsealing of an Indictment charging PATRICK NDUKWE, DAVID TRAVERS, and MICHELLE MARTIN with participating in a fraudulent scheme in which TRAVERS and MARTIN improperly routed trips for Medicaid-funded transportation to NDUKWE’s company, Quality Service Medical Transportation (“Quality”) and facilitated fraudulent Medicaid claims by Quality.  The case is assigned to U.S. District Judge Denise L. Cote.

U.S. Attorney Damian Williams said: “Every day, thousands of government employees and private contractors around New York are entrusted with handling, disbursing, and guarding public funds.  As alleged, David Travers and Michelle Martin, who were employees at the state manager for Medicaid-funded transportation, abused their roles and the public’s trust when they took payments to steer business to a private company and helped that company submit fraudulent Medicaid claims.  This Office and our law enforcement partners will always investigate and prosecute the illegal abuse of public programs for unjust enrichment.”

HHS-OIG Special Agent in Charge Scott J. Lampert said: “The defendants in this case allegedly engaged in a greed-fueled fraud scheme that undermined the Medicaid program and diverted taxpayer funds from their intended purpose of providing health care benefits to low-income individuals and families.  Together with our law enforcement partners, HHS-OIG will continue to vigorously pursue those who steal from government health programs for personal gain.”

HSI Acting Special Agent in Charge Ricky J. Patel said: “As alleged, these defendants lined their pockets by abusing a program created to provide assistance to the sick and injured in our communities.  Working with our partners, HSI will seek out and bring to justice those that attempt to undermine any federal or state program, explicitly those designed to help millions of our most vulnerable in New York.”

As alleged in the Indictment, which was unsealed today, public filings, and statements in court:[1] 

In New York, individuals who are enrolled in the state’s Medicaid program are eligible to have Medicaid pay for their transportation to and from medical appointments if they are not able to safely take public transportation.  To obtain Medicaid-funded transportation, the enrollee or their health care professional must schedule transportation by contacting the private company that is contracted to manage Medicaid-funded transportation in the New York City area (the “Transportation Manager”).

NDUKWE, 56, was the owner and operator of Quality.  From in or about May 2017 to March 2020, Quality was paid more than $7.3 million for more than 120,000 trips the company purportedly provided for Medicaid-enrolled customers in the New York City area.  However, many of these trip claims were fraudulent and never actually performed.  In some instances, the Medicaid-enrollee who purportedly used Quality to travel to a medical appointment had, in fact, never heard of or used the company for any transportation services.  In other instances, the driver who Quality said performed the trip had never actually worked for the company.  In yet other instances, Quality paid a periodic “kickback” to a Medicaid enrollee to use that enrollee’s personal identifying information to submit a trip claim.

TRAVERS and MARTIN were customer service representatives at the Transportation Manager.  Both were responsible for, among other things, receiving calls from Medicaid enrollees who needed transportation and then randomly assigning those trips among the dozens of eligible transportation companies in the New York City area.  However, both TRAVERS and MARTIN steered a disproportionately high volume of their trips to Quality.  In addition, when certain enrollees requested to be moved from Quality to another transportation company, TRAVERS and MARTIN ensured that the customers were eventually reassigned back to Quality.  TRAVERS and MARTIN also scheduled trips for Quality that they knew would not be performed and would allow Quality to submit fraudulent claims for payment.  For their fraud, both TRAVERS and MARTIN received payments from NDUKWE.

*                      *                      *

NDUKWE was arrested this morning in the Bronx and will be presented later today before U.S. Magistrate Judge Ona T. Wang in Manhattan federal court.  TRAVERS was arrested this morning in Syracuse, New York, and Martin was arrested this morning in East Syracuse, New York.  Both TRAVERS and MARTIN will be presented later today before U.S. Magistrate Judge Therese Wiley Dancks.

NDUKWE, TRAVERS, and MARTIN are each charged with one count of theft of government funds, in violation of 18 U.S.C. § 641; one count of health care fraud, in violation of 18 U.S.C. § 1347; one count of conspiracy to commit health care fraud, in violation of 18 U.S.C. § 1349; and one count of violating the Anti-Kickback statute, in violation of 42 U.S.C. § 1320a-7b. In addition, NDUKWE is charged with one count of aggravated identity theft, in violation 18 U.S.C. § 1028A. In February 2020, as part of the same investigation, the Government charged 13 defendants involved in a different transportation company.

The crimes of theft of government funds, health care fraud, conspiracy to commit health care fraud, and violating the Anti-Kickback Statute each carry a maximum sentence of 10 years in prison.  The crime of aggravated identity theft carries a mandatory two years in prison.  The maximum potential sentences in this case are prescribed by Congress and are provided here for informational purposes only, as any sentencings of the defendants will be determined by a judge.

Mr. Williams praised the outstanding work of DHHS-OIG and HSI.  He also thanked the Office of the New York State Medicaid Inspector General, New York Attorney General’s Medicaid Fraud Control Unit, United States Customs and Border Protection, the Syracuse Police Department, the Onondaga County Sheriff’s Office, the Internal Revenue Service, the New York City Police Department, and the U.S. Probation Office for the Northern District of New York for their assistance in the case.

This case is being handled by the Office’s General Crimes Unit.  Assistant United States Attorneys Brandon D. Harper and Kedar S. Bhatia are in charge of the prosecution.

[1] As the introductory phrase signifies, the entirety of the text of the Indictment are herein are only allegations, and every fact described herein should be treated as an allegation.

Clipped from: https://www.justice.gov/usao-sdny/pr/former-employees-state-administrator-medicaid-transportation-and-business-owner-charged

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TN Medicaid paid almost $5M for fake visits at a primary care clinic.

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.

A new audit from the State Comptroller’s Office says the state Medicaid agency overpaid a clinic by $4.7 million.
 

The audit says the Grove Primary Clinic in West Tennessee inaccurately reported patient reimbursements to the state through either mistakes or fraud.

Documents say the clinic inflated their patient count by more than 44,000 visits over a five-year period, from 2014-2019.

TennCare reimbursed the clinic for the overreported visits.

The audit says the clinic is obligated to return overpayments and could be subject to fines.

The clinic couldn’t be reached for comment because it closed just one day after auditors contacted the owners about their examinations.

This audit comes just one week after TennCare was named in a different federal audit.
 

That audit from the federal Office of the Inspector General found the state may owe hundreds of millions of dollars to the federal government due to mistakes, over-billing, and improper documentation.

The director of TennCare strongly refutes the federal audit, calling it frustrating and unreasonable.

“What the audit is claiming is that we overclaimed those federal dollars and of course we disagree with that,” Director Stephen Smith said. “We provided in our opinion completely acceptable and suitable information.

The federal investigation is still active, and TennCare is working to appeal the claims right now.

TennCare declined to comment on the audit on Grove Primary Clinic, referring Fox 17 News to the investigation documents.

Clipped from: https://fox17.com/news/local/audit-shows-state-medicaid-agency-overpaid-clinic-by-47-million