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FRAUD (NC)- Attorney General Josh Stein Announces $1.9 Million Medicaid Settlement with Cary Lab

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]: The NC lab stole $2M in bogus Medicaid claims for urine drug tests.

 
 

Clipped from: https://ncdoj.gov/attorney-general-josh-stein-announces-1-9-million-medicaid-settlement-with-cary-lab/

 
 

For Immediate Release:
Friday, August 4, 2023

Contact: Nazneen Ahmed
919-716-0060

(RALEIGH) Attorney General Josh Stein today announced that Aspirar Medical Lab LLC in Cary and its owner Pick Chay have agreed to pay $1,951,090 to resolve allegations that they violated the law by billing the North Carolina Medicaid program for unnecessary urine drug tests and paying illegal kickbacks for these tests.

“My office will hold accountable health care companies that waste money intended to improve the health of North Carolinians,” said Attorney General Josh Stein. “I’m grateful for the state and federal partnership to protect taxpayers.”

Aspirar allegedly paid two companies for each urine drug test that they referred to Aspirar. It was also alleged that these tests were medically unnecessary where they were not patient-specific and did not reflect an appropriate determination of the patient’s need for the test. Aspirar submitted these clams to Medicaid from March 2016 to September 2017.

The investigation and prosecution of this case was conducted in partnership with the U.S. Attorney’s Office for the Western District of North Carolina, the FBI in Charlotte, and the Office of Inspector General of the U.S. Department of Health and Human Services.

About the Medicaid Investigations Division (MID)

The Attorney General’s MID investigates and prosecutes health care providers that defraud the Medicaid program, patient abuse of Medicaid recipients, patient abuse of any patient in facilities that receive Medicaid funding, and misappropriation of any patients’ private funds in nursing homes that receive Medicaid funding.

To date, the MID has recovered more than $1 billion in restitution and penalties for North Carolina. To report Medicaid fraud or patient abuse in North Carolina, call the MID at 919-881-2320. The MID receives 75 percent of its funding from the U.S. Department of Health and Human Services under a grant award totaling $6,106,236 for Federal fiscal year (FY) 2022. The remaining 25 percent, totaling $2,035,412 for FY 2022, is funded by the State of North Carolina.

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FRAUD (VT)- Attorney General Investigating Brattleboro Retreat for Medicaid Fraud

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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]: The state’s largest psychiatric facility is refusing to comply with auditor requests for information after it pivoted most of its billings to a single, higher-paying code.

 
 

 
 

Clipped from: https://www.sevendaysvt.com/vermont/attorney-general-investigating-brattleboro-retreat-for-medicaid-fraud/Content?oid=38814711

click to enlarge

  • File

The Vermont Attorney General’s Office is investigating the Brattleboro Retreat for potentially defrauding the state.

The probe centers around whether the Retreat violated the Vermont False Claims Act by billing Medicaid for services it never provided. Investigators say they have evidence suggesting that the Retreat may have engaged in an illegal billing practice known as “upcoding,” in which providers overstate the severity of a patient’s illness to receive a higher payment.

The investigation has been under way since 2020 but quietly spilled into public view last week. The AG’s Office filed a petition in court seeking to force the nonprofit hospital to comply with a detailed request for information, known as a civil investigative demand, that it sent in June.


Investigators say the Retreat has refused to comply without legal justification.


“If the False Claims Act is to serve any purpose in interdicting suspected fraud, The Retreat cannot be permitted to stall — or worse yet, evade — an explicit, authorized and relevant State investigative demand,” assistant attorney general Douglas Keehn wrote in a court filing this week. The AG’s Office declined to comment on the matter.


The Retreat refused an interview request and declined to comment on the investigation. But in a statement, a spokesperson said state investigators were seeking documents beyond the scope of their authority.


“Like all hospitals, the Retreat is subject to various audits and reviews, and we look forward to continuing to collaborate with the attorney general’s office in its important oversight function,” the statement read.


The Brattleboro Retreat is Vermont’s largest psychiatric hospital, providing both addiction and mental health inpatient treatment. It has been on shaky financial ground for years, which leaders have blamed in part on the state’s reluctance to raise Medicaid reimbursement rates to keep pace with costs; roughly half of the nonprofit hospital’s revenue comes from Medicaid.

The fraud probe began after the agency that oversees Medicaid — the Department of Vermont Health Access — identified “suspicious” changes to the Retreat’s billing practices, court documents show.

In particular, state investigators found that the Retreat had begun using one specific billing code much more without any explanation. That code, according to court records, results in a “significantly higher” payment than others the hospital once relied on.

The Department of Vermont Health Access reported its findings to the AG’s Office in March 2020. A Seven Days records request for that report was denied on the basis that it could “interfere with enforcement proceedings.”

The report prompted the AG’s Medicaid Fraud & Residential Abuse Unit to subpoena the hospital for documents related to its billing practices.

A review of more than 50,000 pages of material showed that the hospital had “frequently” submitted billing codes that were unsupported by the patient’s diagnosis and treatment, according to the recent court filing. Investigators also found emails referencing pertinent documents that the hospital did not fork over.


The AG’s Office spent a year trying to schedule a meeting with the Retreat’s leadership, the filing says. When the two sides finally met in March 2022, investigators laid out their most concerning findings and requested the still-outstanding documents.


“From that date forward, other than nonspecific assurances of cooperation and requests to repeat information already provided, The Retreat has not provided any substantive response, document or witness,” the filing says.

The hospital has already been the subject of one major state probe in the last decade.

In 2013, then-attorney general Bill Sorrell began investigating whistleblower claims that the Retreat had committed Medicaid fraud. Two years later, Auditor Doug Hoffer recommended the state expand the scope of its investigation.

The probe concluded in 2018, when Sorrell’s successor, T.J. Donovan, announced that while the hospital was deficient in “several areas” of its billing practices, none appeared to have financially harmed the state.


The hospital agreed to hire a third party to review its billing procedures and outline recommendations. Asked on Friday whether those steps were ever accomplished, a spokesperson declined comment.

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State News (NJ, DE) – Nemours may exit NJ Medicaid

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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]: That $20M for a DE hospital from NJ taxpayers? Still not enough.

 
 

https://www.njspotlightnews.org/2023/07/nemours-may-exit-nj-medicaid-and-still-keep-20m-allocation-meant-to-encourage-it-to-stay/

 
 

 
 

State budget dedicated $20M to keep Nemours in NJ Medicaid system, but the provider may pull out — and still collect the money

Credit: (Nikita No Komment via Flickr)

 
 

NJ’s special-needs children

File photo

When New Jersey lawmakers tweaked the state budget to enable a Delaware-based specialized children’s hospital system to collect nearly $20 million more this fiscal year, they expected the system to remain part of the state’s Medicaid network in return.

But a month later Nemours Children’s Health has offered no guarantee it will stay in-network for the majority of patients. Nemours said Friday it had reached an agreement with one of three managed-care organizations that insure a total of 11,000 New Jersey children with significant health needs. But it appears more than 10,000 of these young patients could still be phased out of managed care at Nemours over four months, starting Tuesday. That would force some families to coordinate critical care with a new set of doctors for children with highly specialized medical needs.

The lack of clarity from Nemours has frustrated at least one of the New Jersey lawmakers who helped secure the additional funding in the budget, which took effect July 1, in hopes of keeping the hospital group in the New Jersey Medicaid system. “I find it troubling after this infusion of funding from state government” that Nemours has not announced its intention to remain in-network or initiated new negotiations with insurance companies, said Assemblyman Herb Conaway Jr. (D-Burlington), who chairs the health committee in that house.

“The expectation on the part of the legislature was certainly that this funding support to Nemours would allow them to (remain) in network,” Conaway said Friday, shortly after meeting with one of the insurance companies that covers Medicaid managed-care patients that use Nemours, a Delaware-based system that also has hospitals in Florida. “To find out the two sides are well apart,” Conaway said, “this is problematic.”

Nemours still qualifies for funds

Even if Nemours does phase out the vast majority of its in-network Medicaid patients, the hospital system could still collect the funds under the parameters outlined in the New Jersey budget that took effect July 1. The allocations include a $10 million state-funded grant available through the New Jersey Department of Health, part of more than $340 million in state and federal funds set aside for hospital infrastructure and programs.

New Jersey lawmakers also budgeted $4.5 million in state funds to increase Medicaid rates for Nemours to a level that is essentially 150% of what New Jersey hospitals would get paid for the same services. That makes Nemours eligible to obtain another estimated $4.5 million from the federal government under the Medicaid program, which provides insurance for low-income Americans using a mix of state and federal funds.

It appears more than 10,000 young patients could still be phased out of managed care at Nemours over four months, starting Tuesday.

Nemours officials declined to say last week if the system intended to seek the $10 million grant from the health department, but it appears they have not yet done so and the process could take some time to complete. Officials in the health department said it would reach out to Nemours once a formal notice and application is posted on the agency’s list of grant opportunities. No immediate timeline for this posting was available.

Nemours informed patients and doctors in late April that it would no longer accept managed-care plans in New Jersey Medicaid, also known as FamilyCare. The schedule the system shared calls for patient services for this group to begin to wind down in August, with the process stretching over at least four months. The news sparked concern among a number of families and led one mother to launch a petition urging the nonprofit hospital system — founded with money from the Alfred I. DuPont estate to provide charitable care — to continue accepting FamilyCare. It has now garnered more than 1,800 signatures.

Faulting NJ’s Medicaid reimbursements

Nemours officials said they were committed to caring for special-needs children, but the difficult decision reflected the reality of New Jersey’s low Medicaid reimbursement rates, which are among the lowest in the nation. An analysis late last year found that a surge of patients after the COVID-19 pandemic combined with higher costs and general inflation drove up costs. But limited reimbursements meant Nemours lost “tens of millions” on this group of New Jersey patients, company officials said.

On Friday, a spokesperson for Nemours told NJ Spotlight News it had reached a deal with one system and continued to talk with others, despite what Conaway had said about a lack of negotiations: “Nemours Children’s Health has reached an agreement with WellCare NJ Family Care, so coverage for those patients will continue. Network negotiations such as these are very complex. Unfortunately, they do typically go up until the last minute, and such is the case with this situation. We have continued discussions scheduled with the remaining MCOs before Tuesday, and we are working hard to continue our relationships with all three MCOs in the state of New Jersey.”

‘The expectation on the part of the legislature was certainly that this funding support to Nemours would allow them to (remain) in network.’ — Assenblyman Herb Conaway Jr. (D-Burlington)

NJ Spotlight News was not able to immediately confirm this with WellCare, which insures roughly 5% of New Jersey’s managed-care members statewide. Nemours declined to say Friday how many of its patients would benefit from the new deal with WellCare.

The New Jersey Department of Human Services, which oversees the state’s $20 billion Medicaid plan that covers some 2.2 million residents, declined to comment on the current situation. Leaders there said they were disappointed by Nemours’ decision earlier this year to pull out of the Medicaid system.

Officials with several of the other insurance companies that manage care for New Jersey Medicaid members said they remain confused and surprised by Nemours position, especially since they said Nemours just demanded a rate increase that took effect at the start of this year. As of Friday, Nemours had not rescinded its notice announcing its intention to leave the Medicaid network, starting Tuesday, they said.

Undercutting managed care

Ward Sanders, president and CEO of the New Jersey Association of Health Plans, which represents the managed-care insurance companies, also shared concerns about the additional funding set aside for Nemours in a July 18 email to rulemaking officials at Human Services. The legislative changes to the budget were enacted with little public or stakeholder input he said, and setting rates in this manner undermines the managed-care process, which seeks to reward quality and efficiency.

Sanders also noted — pointing to a recent story in NJ.com — that while the new funding was designed to keep Nemours in-network, there is no requirement that it remain to access the additional money. “The state’s favorable treatment of certain out-of-state hospitals appeared to come with the expectation that facilities would stay in-network to serve Medicaid beneficiaries. Yet recent reporting indicates that there was no promise to remain in-network and so far at least one affected facility has not confirmed whether it intends to retract its contract termination notices,” he wrote.

Conaway, a physician himself, is also concerned about the impact on children and families. Many of the children now receiving treatment at Nemours may be able to continue to access services there through single-case agreements, the price of which is negotiated between the hospital and the insurance company, he said.

“Some patients will struggle to get care,” Conaway said, and it is likely to cost parents more time on the phone or online to fill out insurance paperwork — a process he said lawmakers had hoped they could avoid by increasing Nemours funding.

Insurance companies acknowledge it will require more work, but note they are responsible for ensuring each child has access to appropriate care, regardless of where the hospital is located or if it is in-network with New Jersey Medicaid. “Their well-being is protected,” Conaway said, “but there’s the stress one would hope would have been avoided. That was the expectation, at least.”

 
 

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STATE NEWS (CA)- Industry groups in California vie for new Medicaid money

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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]: “Stakeholders” begin the process of trying “advise” on the divvy-it up formula should work on the $11.1B from the MCO tax.

 
 

Clipped from: https://www.news-medical.net/news/20230721/Industry-groups-in-California-vie-for-new-Medicaid-money.aspx

California’s powerful health care industry just notched a historic win: The state is going to give it an $11.1 billion infusion to improve care for millions of low-income Medicaid patients.

Top state health officials say they plan to plow most of the money into higher payments for doctors, hospitals, and other health care providers who serve Californians covered by Medi-Cal, the state’s Medicaid program. But the framework, hammered out this summer as part of state budget negotiations, lacks critical details, which has set off a lobbying frenzy among health industry groups seeking a cut.

Even as they battle for their share, industry leaders are quietly plotting a November 2024 ballot initiative to lock in the Medi-Cal payment increases, which they argue are needed to sustain the safety-net program that covers nearly 16 million Californians — a staggering 40% of the state’s population.

“We are addressing decades of systemic underfunding in Medicaid that has exacerbated inequity and health care provider deserts, where patients are often forced to get their care in emergency departments,” said Dustin Corcoran, the CEO of the influential California Medical Association, which represents doctors.

Corcoran also leads the coalition negotiating with Gov. Gavin Newsom and fellow Democratic lawmakers in Sacramento over how the money — a combination of state and federal funding to be doled out over six years — will be spent.

“Even with this historic deal, there are still parts of the health care system that are going to struggle to provide the care that patients need,” Corcoran said. “The coalition is dedicated to ensuring long-term stability and predictability in reimbursement rates in California.”

California has among the lowest Medicaid reimbursement rates in the country, which is often cited as a key reason many low-income patients can’t get care and often face excruciating wait times, especially for primary care, obstetric, and mental health appointments, said Kathryn Phillips, the associate director for improving access to care at the California Health Care Foundation. (KFF Health News publishes California Healthline, which is an editorially independent service of the California Health Care Foundation.)

“That’s where the state is struggling the most,” she said. “Low rates are why a physician may not accept Medi-Cal patients, or only accept a low number of patients.”

This deal funds the largest increase in base Medi-Cal reimbursement rates in at least 25 years, said Jennifer Kent, a former director of the state Medicaid agency.

The money will come from the managed care organization tax, which has been levied since 2005 on health insurers that do business in California. Revenue from the tax, which allows the state to secure billions in federal health care dollars it wouldn’t otherwise receive, has previously been funneled into the state general fund, which can be used for anything state leaders want.

Under the deal, and for the first time, Newsom and the legislature have agreed to use the money to improve care for poor Californians. Of the $19.4 billion projected to be raised by the tax between 2023 and 2026, $11.1 billion will go directly to Medi-Cal and $8.3 billion to the general fund to offset state spending on Medi-Cal, according to state Department of Finance spokesperson H.D. Palmer.

The new funding will start flowing next year, with $820 million earmarked for initial rate increases in primary care, obstetric care, and mental health care, Palmer said.

From 2025 through 2029, the state plans to allocate nearly $2.7 billion a year, according to the department. State and industry officials said they plan to direct some of the money to expand medical residency programs for doctors serving low-income people, fund new beds for psychiatric patients, and increase the workforce of other providers such as nurses, mental health therapists, and community health workers.

But the bulk will go to rate increases for primary care and an array of providers and services, including hospitals and long-term care facilities, abortion care, and emergency services. Higher rates for specialists, such as psychiatrists and dentists, are also desperately needed.

Although Newsom and state health officials have promised to direct the money to health care providers, they haven’t specified which ones will get increases — and there’s no guarantee the money won’t be diverted to another program. Medi-Cal, a massive and ballooning program with a budget of $152 billion this fiscal year, is under tremendous pressure. The state continues to expand the program to more people and offers a growing list of expensive services, despite the threat of budget deficits.

“There has to be more guardrails,” said Assembly member Vince Fong (R-Bakersfield) during a June legislative debate. “This should not be seen as a revenue grab.”

Mark Ghaly, Newsom’s health and human services secretary, acknowledged that even though some providers and treatments may be left out initially, the payment boosts represent a critical step toward better access.

“The core providers in Medicaid will benefit,” Ghaly told KFF Health News. “There’s always going to be someone out there with a question and a concern, and I hope that as we learn about them and we hear them, we address them.”

Ghaly said the tax will bring some Medicaid rates in California from the bottom in the country to the top. While he acknowledged concerns that the money might be diverted in future years, he said Newsom is committed to spending it on Medi-Cal. “Who knows about the uncertainty of the future?” he said. “But we have basically done as much as you can to hard-wire these changes into the way we design Medicaid. The man with the pen — the governor of California — is committed to this.”

Even though the tax deal isn’t big enough to fix all the problems in Medi-Cal, it will improve patient care, said Charles Bacchi, president and CEO of the California Association of Health Plans, which represents private and public insurers.

“There’s a lot more work to do hammering out the rate increases and where they should go,” Bacchi said. “We have to make sure that the funding actually survives the budget process next year.”

Some providers worry they may be left out.

“We’ve argued hard for optometrists to be included,” said Kristine Schultz, executive director of the California Optometric Association, noting that optometrists can’t afford to treat poor patients because of low rates. For example, optometrists get about $39, on average, to conduct an eye exam on a new Medi-Cal patient, while Medicare reimburses $158, she said.

As a result, she said, patients “are not able to get in for months.”

Ann Rivello, a therapist in San Mateo County specializing in trauma, also cited low rates — and complicated medical billing demands — as the reasons she doesn’t accept Medi-Cal patients.

“I’ve been practicing over 20 years and I do not accept Medi-Cal even though it’s within my values,” she said.

Detailed rates for most health care treatments for Medi-Cal patients are not publicly available because they are negotiated privately by insurance companies and vary by geography and health insurance plan. And the state has a slew of bonus payments it uses to supplement base Medi-Cal rates, further obfuscating how much health care providers receive.

While Medi-Cal rates vary widely, on average, California reimburses 76% of Medicare rates, Phillips said. Next year, the state plans to raise that base payment rate to 87.5% of Medicare in three target areas — primary care, obstetrics, and mental health.

As health care providers battle for their slice of the tax revenue, they say they want to avoid the same lobbying fight each time the state renews the tax, which happens every few years. One option they are considering: a ballot initiative next year that would lock the Medi-Cal funding into the state constitution.

Bacchi declined to take a position on the concept but said insurers are “taking a look at it.” He argues that California “needs to make a long-term commitment to the Medi-Cal program.”

John Baackes, the CEO of L.A. Care, the largest Medi-Cal insurer, supports the idea. He argues that a permanent increase in Medi-Cal rates would help address the disparities between Medi-Cal and private insurance coverage.

“The pandemic showed us that inequality is a life-and-death matter, because if you look at the people who got sick the most and died, they were people of color,” he said. “If we continue to ignore that, we’re idiots.”

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

 
 

This article was reprinted from khn.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

 

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FWA (CA)- Pain clinic chain to pay $11.4M to settle Medicare and Medicaid fraud claims

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]: Lots of painful, unnecessary procedures done on Medicaid patients in CA and OR. You paid $11.4M to make it happen.

 
 

https://www.fiercebiotech.com/medtech/pain-clinic-chain-pay-114m-settle-medicare-and-medicaid-fraud-claims

 
 

 
 

SACRAMENTO, California—The owner of one of California’s largest chains of pain management clinics has agreed to pay nearly $11.4 million to California, Oregon, and the federal government to settle allegations of Medicare and Medicaid fraud.

The U.S. Department of Justice and the states’ attorneys general say Francis Lagattuta, a physician, and his Lags Medical Centers performed—and billed for—medically unnecessary tests and procedures on thousands of patients over more than five years. It was “a brazen scheme to defraud Medicare and Medicaid of millions of dollars by inflicting unnecessary and painful procedures on patients whom they were supposed to be relieving of pain,” Phillip Talbert, U.S. attorney for the Eastern District of California, said in a statement this month.

The federal Medicare program suspended reimbursements to Lags Medical in June 2020, and Medi-Cal, California’s Medicaid program, followed in May 2021. Lags Medical shut down the same day the state suspended reimbursements. The company, based in Lompoc, California, had more than 30 pain clinics, most of them in the Central Valley and the Central Coast.

KFF Health News review last year found the abrupt closure left more than 20,000 California patients—mostly working-class people on government-funded insurance—struggling to obtain their medical records or continue receiving pain prescriptions, which often included opioids.

Lagattuta and Lags Medical did not admit liability under the settlement. Lagattuta denied the governments’ claims, saying in a statement he was “pleased” to announce the settlement of a “long-standing billing dispute.” As part of the agreement, Lagattuta will be barred for at least five years from receiving Medicare and Medicaid reimbursements.

“Since the Centers have been closed for a couple of years, it made sense for Dr. Lagattuta to settle the dispute and continue to move forward with his other business interests and practice,” Malcolm Segal, an attorney for Lagattuta and the centers, said in the statement.

According to state officials, the federal government will receive the bulk of the money, about $8.5 million. California will receive about $2.7 million, and an additional $130,000 will go to Oregon. The settlement amount is based in part on Lagattuta’s and Lags Medical’s “ability to pay.” It does not cover the governments’ full losses, which the U.S. attorney’s office in Sacramento said are not public record.

A nearly four-year investigation by federal officials and the California Department of Justice found that from March 2016 through August 2021, Lagattuta and his company submitted reimbursement claims for unneeded skin biopsies, spinal cord stimulation procedures, urine drug tests, and other tests and procedures. Lagattuta began requiring all his clinics to perform various medical procedures on every patient, the officials said, no matter if they were needed or requested by patients’ medical providers. Patients who refused were told they would have their pain medication reduced and could suffer adverse medical consequences.

U.S. and California investigators piggybacked on a federal claim filed in late 2018 by a whistleblower, Steven Capeder, Lags Medical’s former operations and marketing director, who will receive more than $2 million of the settlement.

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FWA (KS)- AG’s Medicaid fraud unit recoups $42,000 in restitution

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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 group of 6 small-time fraudsters, mostly for bogus personal care attendant claims.

 
 

 
 

https://fortscott.biz/news/ags-medicaid-fraud-unit-recoups-42000-in-restitution

 
 

 
 

TOPEKA – (July 31, 2023) – The Kansas Attorney General’s Medicaid Fraud and Abuse Unit (MFCU) recently prosecuted six Medicaid fraud cases recouping more than $42,600 in restitution from fraudsters, Kansas Attorney General Kris Kobach announced today.

“Our top priority is the protection of crime against one of the most vulnerable groups of our population – the elderly and disabled. These prosecutions should put Medicaid fraudsters on alert. If you hurt Kansas’s most vulnerable, we will prosecute,” said Jackie Williams, First Assistant Attorney General for Kobach’s office.

The AG’s MFCU unit is dedicated to ensuring that Kansas citizens receive the services Medicaid is allocated to provide. The unit investigates and prosecutes Medicaid fraud cases statewide to stamp out corruption and abuse of Medicaid dollars and services.

The unit’s recent cases include the prosecutions of:

  • Michelle Kisha Taylor of Shawnee. She pled guilty to making a false claim, statement or representation to the Medicaid Program and unlawful acts concerning computers and was sentenced to 24 months in jail, suspended, and 12 months supervised probation. She was ordered to pay more than $12,000 in restitution to the Kansas Medicaid program for Medicaid fraud. While working another job, Taylor was working as a personal care attendant for her mother, a Medicaid beneficiary. Taylor submitted fraudulent claims for payment to the Medicaid program as if she was providing personal care services to her mother, when in reality, she was working another job or her mother was in the hospital. Taylor’s prosecution was part an “Operation Keeping Them Honest,” a cooperative effort between the attorney general’s office and the U.S. Department of Health and Human Services/Office of Inspector General to investigate fraudulent billing to Medicaid for personal care services provided in Medicaid beneficiaries’ homes. Senior Assistant Attorney General Eve Kemple of Kobach’s office prosecuted the case. She was assisted by analyst Dalton May.
  • Marquita Francine Standard of Lansing. Standard pled guilty to one count of making a false claim, statement or representation to the Medicaid Program. Standard, a personal care attendant, submitted false claims for payment from Medicaid as if she was providing care to several beneficiaries residing in different locations, all at the same time. Standard was sentenced to six months in the Kansas Department of Corrections, suspended, and 12 months supervised probation. She was ordered to pay $4,093 in restitution. Her case was also part of the “Operation Keeping Them Honest” program. Kemple prosecuted the case with assistance from analyst Sharon Balmain.
  • Myshia Robertson, 49. Robertson pled guilty to making a false claim to the Medicaid program. She submitted a fraudulent claim to Medicaid for personal care services she did not provide. She was sentenced to nine months in jail, suspended, and 12 months supervised probation. She was ordered to pay $18,200 in restitution – the amount Medicaid lost from her false claims. Assistant Attorney General Debbie Moody of Kobach’s office prosecuted the case with assistance from special agent Natasha Ward, analyst Kim Epps, and nurse investigator Kimberly Smith.
  • Courtland Edward Allen, 35 of Leavenworth. Allen pled guilty to making a false claim, statement, or representation to the Medicaid program and unlawful acts concerning computers. Allen claimed to be working as a personal care attendant for his brother, a Medicaid beneficiary, when Allen was actually working another job and times when his brother was in school. Allen was sentenced to 24 months in jail, suspended, and 12 months supervised probation. He was ordered to pay $3,687 in restitution. Kemple of Kobach’s office prosecuted the case with assistance from special agent Ward and analyst Epps.
  • Kevin Matney, 51 of Garnett. In a civil action, Matney was charged with making false claims. He agreed to pay $4,202 in restitution as part of a settlement agreement. Kemple litigated the case. Special Agent Julie Hart, analyst Kimberly Clearwater, and nurse investigator Smith assisted with the case.
  • Kierra Drinnen, 37 of Sedgwick County. Drinnen confessed to fraud. Drinnen worked as a clinical coordinator nurse in Wichita. While on duty, she stole medication that was paid for by Medicaid for a Medicaid patient. She agreed to a plea deal for that included a sentence of 12 months of jail time, suspended, and 12 months supervised probation. She agreed to continue in substance abuse treatment. Drinnen must pay all court costs in addition to standard conditions of probation. Moody of Kobach’s office handled the case. She was assisted by investigators Kevin Kasl and Smith of the attorney general’s office.

To report suspected cases of Medicaid fraud or abuse, please call 1-866-551-6328 or (785) 368-6220 or click here to use our online reporting form.

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CONTACT: Danedri Herbert – (913) 706-6394 danedri.herbert@ag.ks.gov

 
 

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FWA (TX)- Texas Attorney General’s Medicaid Fraud Control Unit Helps Secure 49-Month Sentence and Over $5 Million Restitution in Orthopedic Supplies Fraud Case

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]: Decent-sized DME fraud, mostly for orthopedic equipment made possible by kickbacks to marketers.

 
 

https://www.texasattorneygeneral.gov/news/releases/texas-attorney-generals-medicaid-fraud-control-unit-helps-secure-49-month-sentence-and-over-5Kenric

 
 

 
 

Wakeen Griffin, co-owner of New Horizons Durable Medical Equipment based in Frisco, TX, was sentenced to 49 months of federal incarceration to be followed by a year of supervised release for his role in a medical equipment fraud scheme. In addition, Griffin was ordered to pay $5,114,016.19 in restitution to government health care programs. A jury convicted Griffin of conspiracy to defraud the United States and to pay and receive healthcare kickbacks, as well as seven counts of payment and receipt of kickbacks. 

Griffin obtained patients by offering and paying kickbacks to marketers as well as disguising illegal payments as marketing services and outsourced business services. Griffin then submitted false claims to both Medicaid and Medicare for orthopedic equipment that was never provided, not medically necessary, and not authorized by a physician. 

The investigation was conducted by Sergeant Doug Wood, Investigative Auditor Jennifer Blakely, and Captain Justin Boyce of the Texas Medicaid Fraud Control Unit (“MFCU”) in partnership with the Federal Bureau of Investigation and the U.S. Department of Health and Human Services’ Office of Inspector General. The case was prosecuted by the Department of Justice Health Care Fraud Strike Force. 

The OAG’s Medicaid Fraud Control Unit is dedicated to ensuring that those who exploit our healthcare system for personal gain are brought to justice by aggressively pursuing those who engage in healthcare fraud, working to safeguard taxpayer funds, and defending the integrity of vital healthcare programs. In the last fiscal year alone, the MFCU recovered more than $236 million in settlements and judgments for Texas taxpayers. In Texas, Medicaid costs taxpayers over $40 billion per year. Federal and industry authorities estimate that fraud comprises up to ten percent of the costs of the Medicaid program, making Medicaid fraud a $4 billion problem in Texas.   

The MFCU receives 75 percent of its funding from the U.S. Department of Health and Human Services under a grant award totaling $20,944,200 for fiscal year 2023. The remaining 25 percent, totaling $6,981,395, is funded by the State of Texas. For every dollar of state funding, the OAG’s MFCU recovers more than 33 dollars for taxpayers. If you suspect Medicaid fraud or abuse, or patient neglect, please report it by visiting the OAG’s website

 
 

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FRAUD (OH)- Valley doctor gets probation, ordered to pay $75K for Medicaid

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]: One doc paid 2 other docs to send samples for bogus gonorrhea and chlamydia tests.

 
 

 
 

Clipped from: https://www.wfmj.com/story/49257629/valley-doctor-gets-probation-ordered-to-pay-dollar75k-for-medicaid-and-medicare-kickback-scheme


A Valley doctor has been sentenced for her role in a Medicare and Medicaid kickback scheme.

Dr. Michelle Kapon of Youngstown was sentenced to two-years probation and ordered to pay a $75,000 fine.

According to court documents, Kapon and OBGYN Joni Canby received kickbacks from OBGYN Samir Wahib after sending samples from their patients to him for gonorrhea and chlamydia testing.

Investigators said Wahib would pay Canby $20 and Kapon $15 for every specimen sent his way. Wahib would then allegedly submit claims to the federal government for payment for the tests.

The government claimed the payments were disguised as “physician coverage” on checks from his business.

Between 2014 and 2017, Wahib paid $31,520 to Kapon and Canby over a three-year period.

After pleading guilty, Dr. Kapon cited the influence of the other doctors as a reason for a lenient sentence.

A memorandum filed in U.S. District Court through Kapon’s attorney referred to her relationships with the other two doctors, claiming that Dr. Canby was Kapon’s mentor and became increasingly influential in her life.

“In short, Dr. Canby had become embedded into Dr. Kapon’s life. Dr. Kapon completely trusted Dr. Canby’s judgment. This proved to be misplaced,” attorney Ronald Yarwood wrote.

Yarwood’s memo also claimed that as OB-GYN Department Chair for Northside Hospital, Dr. Wahib had the power to mandate certain requirements on Dr. Kapon, including that she must always have a board-certified OB-GYN available during delivery, and she must always have a call coverage for any patients when she is not available.

The memorandum asked the judge to fine Kapon, sentence her to probation, and order her to pay $37,730 in restitution.

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FWA (NC)- Former Charlotte housing provider sentenced in $15M Medicaid fraud scheme

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]: They forced tenants in their subsidized housing program to do unnecessary drug tests, and then submitted those tests for payment to Medicaid.

 
 

 
 

https://www.wsoctv.com/news/local/former-charlotte-housing-provider-sentenced-15m-medicaid-fraud-scheme/DQCOAQTGQNF6VJJNOHBI3F4BKA/

 
 

 
 

CHARLOTTE — A 54-year-old Indiana woman was sentenced to 30 months in prison for her role in a $15 million conspiracy to defraud the North Carolina Medicaid program, the U.S. Attorney for the Western District announced Tuesday.

PAST COVERAGE: Federal jury convicts Charlotte man for role in massive healthcare fraud scheme

Jordan will also get three years of supervised release and must pay $5.88 million in restitution.

Jordan was the owner of Legacy Housing, which provided subsidized housing to tenants in Charlotte and Greensboro, according to court documents.

Jordan’s co-conspirator, Donald Booker, owned and operated United Diagnostic Laboratories, a urine toxicology testing laboratory.

 
 

(WSOC)

They also owned and operated United Youth Care Services, which is a company that provided mental health and substance abuse treatment services.

Jordan and Booker conspired with others to defraud Medicaid between January 2018 and December 2020 through a fake drug-testing scheme of urine samples from Medicaid-eligible beneficiaries, according to the U.S. attorney.

Jordan previously admitted in court they recruited housing-vulnerable people and other Medicaid-eligible beneficiaries for housing and other programs and services, the U.S. attorney said.

Once enrolled, the beneficiaries were required to submit urine specimens for drug testing as a condition of the program. The specimens were provided to UDL and UYCS for medically unnecessary urine drug testing, the U.S. attorney said.

Booker and his co-conspirators paid Jordan a kickback from the Medicaid reimbursements on the drug testing. Jordan also conspired with Booker to execute a conspiracy to launder the fraudulent money to conceal and disguise the nature and source of the illegal kickback payments for the illicit drug-testing referrals.

 
 


(WSOC)

On December 9, 2022, Jordan pleaded guilty to healthcare fraud conspiracy and conspiracy to commit money laundering.

In January 2023, Booker was convicted at trial of conspiracy to commit health care fraud, multiple violations of the Anti-Kickback Statute, money laundering conspiracy, and money laundering.

Booker is awaiting sentencing.

©2023 Cox Media Group

 
 

 
 

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FRAUD (VA)- Audit finds Virginia paid nearly $22 million for dead Medicaid patients

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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]: Before the system was improved, VA MCOs got paid millions in monthly cap rates for people who were dead.

 
 

 
 

Clipped from: https://www.wric.com/news/virginia-news/audit-finds-virginia-paid-nearly-22-million-for-dead-medicaid-patients/

 
 

The head of Virginia’s Medicaid office wrote in a June letter that the state has worked to fix the issue and has already recouped much of the money.

RICHMOND, Va. (WRIC) – Virginia paid insurers to cover Medicaid services for patients who had already died, a nearly $22 million mistake over three years that the state is working to recover and repay.

A recent federal audit found that the Virginia Department of Medical Assistance Services, the state’s Medicaid office, accidentally paid out capitation payments – or monthly fixed payments for each enrollee – to Medicaid managed care organizations on behalf of dead patients from 2019 through 2021.

The audit from the U.S. Health and Human Services’ inspector general’s office — first reported by the Richmond Times-Dispatch — estimated that the payments totaled at least $21.8 million on behalf of just over 12,000 enrollees.

“Virginia made unallowable capitation payments on behalf of deceased enrollees because it did not have adequate controls in place to enable it to identify all deceased enrollees and properly cancel their enrollment,” the July 19 audit states.

300,000 Virginians could lose Medicaid coverage: What to know as pandemic protections end

The inspector general’s office recommended that Virginia refund the federal government’s share of the payments – $15.7 million – and recover payments mistakenly paid to insurers.

Its audit also recommended that Virginia recover payments made on behalf of dead Medicaid enrollees in 2018 and 2022, repay the federal share, implement an “additional supervisory review” and use an automated matching and eligibility process to determine enrollees.

A DMAS spokeswoman said Tuesday that the agency had no comment. But in a June 13 letter to the inspector general’s office, DMAS Director Cheryl J. Roberts laid out details about the agency’s process for identifying dead enrollees and its response to the audit’s recommendations.

DMAS gets death files from the Virginia Department of Health through a monthly data exchange, Roberts wrote, using an algorithm to cross reference Medicaid enrollees into categories of either 100% matches or possible matches.

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“After proper notification, state staff within the Eligibility and Enrollment Services Division would manually close all 100% matches and research those enrollments with a lesser match rate,” Roberts wrote. “This process was found to be inefficient as the level of manual work would often take up to a month to complete.”

In response, Virginia implemented an automatic system in January to close the 100% matches. The new system, Roberts wrote, has helped speed up the process and reduce human error. It retroactively closes enrollments back to when the patient died, initiating Virginia’s recoupment of any payments made on behalf of dead enrollees.

Roberts wrote that, as of June 9, the payments made during the audit period of 2019 through 2021, except for nearly $96,000, have been recouped. Also, the payments made on behalf of dead enrollees in 2022 have been recouped and all but $226,023 from 2018 payments have been recovered.

DMAS will work with the Center for Medicaid and CHIP Services’ audit and review branch to repay any outstanding debt that has not been repaid already, Roberts added in her letter.