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FWA- NY Comptroller audit reveals months totaling billions in improper Medicaid payments

 
 

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]: Auditor finds millions in waste, again. State officials say “don’t worry we have it handled,” again.

 
 

Clipped from: https://cbs6albany.com/news/you-paid-for-it/ny-comptroller-audit-reveals-months-totaling-billions-in-improper-medicaid-payments-s-third-party-health-insurance-ny-doh-department-of-health-dinapoli

 
 

 
 

New York State Comptroller Thomas DiNapoli has released an audit of the Department of Health’s Medicaid claims processing program that he says identified more than $22 million in improper Medicaid payments from October of 2021 through March of 2022.

Among the findings from the comptroller, $11.5 million was paid for managed care premiums on behalf of Medicaid recipients who also had concurrent comprehensive third-party health insurance.

MORE: NYS Comptroller: Office of Children and Family Services needs to better-protect children

$8.9 million was paid for clinic, practitioner, inpatient, managed care and laboratory claims that did not comply with Medicaid policies, such as billing in excess of permitted limits.

In response, the Department of Health said the Office of the Medicaid Inspector General continuously performs audits of Medicaid payments, and the DOH says it will continue to work to recover overpayments as appropriate.

MORE: Governor signs bill to restore comptroller’s oversight powers for state contracts

As a result of the audit, about $9.9 million of the improper payments had been recovered by the end of the audit fieldwork.

During the six-month period in question, the DOH processed more than 294 million claims, resulting in payments to providers of nearly $42 billion.

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Expansion (MS)- Every Medicaid expansion bill dies without debate or vote

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]: MS lawmakers immune to advocate arguments.

 
 

Clipped from: https://mississippitoday.org/2023/02/01/medicaid-expansion-bills-die/

 
 

Speaker of the House Philip Gunn (AP Photo/Rogelio V. Solis)

More than 15 bills that would have expanded Medicaid to provide health care coverage to primarily the working poor died on Tuesday night without debate or a vote.

No committee chair in either the Senate or House held a hearing on those Medicaid expansion bills. The House Medicaid Committee, where Speaker of the House Philip Gunn assigned all of the his chamber’s expansion bills, did not even meet a single time before the Jan. 31 deadline to consider general bills.

READ MORE: ‘What’s your plan, watch Rome burn?’: Politicians continue to reject solution to growing hospital crisis

Legislative leaders killed the bills as a worsening hospital crisis grips the state and Mississippi continues to be among the unhealthiest states with the highest percentages of uninsured residents.

State Health Officer Dr. Daniel Edney told lawmakers in late 2022 that 38 hospitals across the state are in danger of closing, and all are facing financial hardships. Physicians and hospital leaders have said expanding Medicaid, which would result in more than $1 billion annually in additional federal health care dollars coming to the state, would help hospitals pay their bills. Beyond just helping hospitals, expanding Medicaid would provide health care coverage to many more Mississippians — up to 300,000, according to some studies.

 
 

But many in the Republican leadership of the state, primarily Gunn and Gov. Tate Reeves, have been adamant in their opposition to expanding Medicaid as 39 other states have done, including many led by Republican politicians.

Meanwhile, data shows that support for Medicaid expansion is growing among voters. A Mississippi Today/Siena College poll conducted in early January indicated that the vast majority of the general public, including 70% of Republican voters, favor expansion.

READ MORE: Poll: 80% of Mississippians favor Medicaid expansion

Rep. Robert Johnson, the House Democratic leader from Natchez, said the death of the bills this week was disappointing but not surprising.

Referring to Gov. Reeves’ State of the State speech earlier this week, Johnson pointed out that he spoke of health care alternatives rather than focusing on solutions for hospitals. Those could include stand-alone surgery centers, telemedicine and other alternatives.

“It seems he is talking about providing health care for selected people,” Johnson said, referring to those who would have health care alternatives that often require some type of insurance — either private or public like Medicaid.

While the Medicaid bills died, still alive is a more modest proposal to provide coverage for new mothers on Medicaid for a year instead of the current 60 days. The Senate is expected to pass the bill in the coming days and send it to the House for consideration.

Last year the Senate passed the bill to lengthen postpartum care from 60 days to one year, but it died in the House in large part because of opposition from Gunn and his health care leadership team, Public Health Chair Rep. Sam Mims of McComb and Medicaid Committee Chair Rep. Joey Hood of Ackerman.

While the Medicaid expansion bills all died, Johnson said there might be legislation that is alive where amendments could be offered to expand Medicaid.

“We will be vigilant in looking for every opportunity we can find to offer amendments to expand Medicaid and to provide needed money to hospitals in the short term,” Johnson said. “We have been here a month now and have not addressed that issue.”

READ MORE: Key bills — including Medicaid expansion — to watch in the 2023 Mississippi legislative session

 
 

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RX- Medicaid Net Drug Spend HIts Double-Digits for the First Time, Says Magellan Rx Report

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]: Specialty drugs continue to drive Medicaid drug spending, and its getting faster, with 2021 being the first year an increase this size has been seen in overall Medicaid Rx spending.

 
 

 
 

 
 

Clipped from: https://www.managedhealthcareexecutive.com/view/medicaid-net-drug-spend-hits-double-digits-for-the-first-time-says-magellan-rx-report

Spending on specialty drugs fueled a 11% increase in Medicaid drug spending from 2020 to 2021, says Magellan’s seventh annual Medicaid Pharmacy Trend Report.

Net Medicaid drug costs increased by 11% from 2020 to 2021, according to Magellan Rx Management’s Medicaid Pharmacy Trend Report, which was published earlier today. It is the first time during the seven-year history of Magellan’s report on Medicaid drug expenditures trend that the increase has been in the double digits, according to the report.

As is true for drug spending for almost all payers, specialty drugs — expensive drugs for rare disease — are accounting for a growing share of Medicaid drug spending and the year-to-year increases in spending, or “trend,” according to the Magellan.


Source: Magellan Rx Management Medicaid Pharmacy Trend Report, 7th edition

The report says the specialty net trend rose 2.1 percentage points from 10.9% in 2020 to 13% in 2021 while the traditional net trend rose 4.1 percentage points from 1.9% to 5.8%. In 2021, specialty drugs accounted for small fraction of drug claims — just 1.3% — but for the majority — 53.8% — of the net drug costs, according to the Magellan report. That is a 2.3 percentage point increase from 2020 when specialty drugs accounted for 51.5% of total net drug costs.

Net costs are often used analysis and calculations of Medicaid drug costs because the difference between the gross and net spending is so large. Medicaid programs receive in a mandatory 23.1% rebate from manufacturers and additional rebates for many drugs on top of that mandatory rebate. According to the Magellan’s numbers, the net cost per claim in 2021 was $58.55, or just 41% of the gross cost per claim of $142.18.

Magellan’s report is not based on drug prices and spending for all Medicaid programs. Rather, the report is based on data for the company’s fee-for-service pharmacy programs in 24 states and the District of Columbia. The report says the data set used to prepare this report included 95 million claims with a gross cost of $13.6 billion and a net cost of $5.6 billion.

Late last year, Prime Therapeutic finalized the $1.35 billion acquisition of Magellan Rx, the pharmacy division of Magellan Health, from Centene Corporation.

The report identifies the specialty drugs most responsible for the increase in spending on specialty drugs. Topping the list are Hemlibra (emicizumab), a treatment for hemophilia A treatment; Trikafta (elexacaftor, tezacaftor, and ivacaftor), a treatment for cystic fibrosis; Evrysdi (risdiplam), a treatment for spinal muscular atrophy; Biktarvy (bictegravir, emtricitabine, tenofovir alafenamide, an HIV treatment; and Stelara (ustekinumab), a treatment for plaque psoriasis, Crohn’s disease and ulcerative colitis.

The report also ranks 50 drug classes by their share of the net spend in 2021. Drugs for HIV/AIDs ranked the highest, accounting for 10% of the net Medicaid spend in 2021. They were followed by antipsychotics (8.4%), hemophilia treatment (7.2%), anticonvulsants (6.3%), oral cystic fibrosis drugs (5.6%) and cytokine and CAM (cell adhesion molecule) antagonists (4.3%), a group that includes Stelara and Humira (adalimumab).


Source: Magellan Rx Management Medicaid Pharmacy Trend Report, 7th edition

Drugs for spinal muscular atrophy, a group of inherited diseases that damage and destroy motor neurons, was further down on the list, ranking 13th and accounting for 1.5% of the net spend. But the report says that claim volume increased by 425% as prescriptions for Evrysdi increased and the market share of Spinraza (nusinersen), delivered via an intrathecal injection, shrank.

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FWA (KS)- Johnson Co. woman ordered to pay $31K in restitution for Medicaid Fraud

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]: You gave Carol $31k for false personal care attendant claims. She did not say thank you.

 
 

Clipped from: https://www.wibw.com/2023/01/26/johnson-co-woman-ordered-pay-31k-restitution-medicaid-fraud/

 
 

A Johnson Co. woman has been sentenced for Medicaid fraud and has been ordered to pay $31,000 in restitution to the Kansas Medicaid program.(Office of the Attorney General)

JOHNSON CO., Kan. (WIBW) – A Johnson Co. woman has been sentenced for Medicaid fraud and has been ordered to pay $31,000 in restitution to the Kansas Medicaid program.

Kansas Attorney General Kris Kobach announced Wednesday that Carol Elaine Hensley, 63, of Overland Park, has pleaded guilty to one count of making a false claim, statement, or representation to the Medicaid program and one count of unlawful acts concerning computers in Johnson Co. District Court. The court judge sentenced Hensley to 24 months behind bars, but that sentence has been suspended; Hensley has now been ordered to serve one year of supervised probation and pay $31,174.49 in restitution.

According to Kobach’s office, investigators looking into Hensley’s case discovered that she served as a personal care attendant for her two adult children, who also happen to be Medicaid beneficiaries. As investigators looked further, they found that Hensley submitted claims for payment to the Medicaid program as if she were providing services to her adult children from January 1, 2018, to February 28, 2022. However, investigators said that Hensley was instead working at different jobs and signed up her adult children for in-day support services.

Kobach said that Hensley’s case is part of an ongoing, cooperative effort between the Kansas Attorney General’s office and the U.S. Department of Health and Human Services/Office of Inspector General called “Operation Keeping Them Honest.” The collaboration is focused on investigating fraudulent billing to the Medicaid program for personal care services in the homes of Medicaid beneficiaries.

Kobach’s office said that nine cases have, so far, been filed within the courts, and five cases have reached the sentencing phase.

The Attorney General’s office said that the other cases are ongoing, joint investigations conducted by the federal and state authorities and prosecuted by Kobach’s Medicaid Fraud and Abuse Division.

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FWA (PA)- Three Montgomery County dentists bilked Medicaid for millions, a federal indictment says

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]: Three brothers ran an absolutely massive dental empire, full of fraud. The thing that finally got em collared? Implanting unapproved medical devices they developed in the mouths of Medicaid patients. You paid them at least $4M in fraud just for the embezzling part.

 
 

 
 

Clipped from: https://www.inquirer.com/news/medicaid-fraud-dentists-bhaskar-savani-biranjan-savani-montco-pennsylvania-federal-indictment-20230125.html

Prosecutors say Bhaskar, Arun, and Niranjan Savani broke at least a dozen laws in their efforts to generate millions in profits between 2009 and last year.

 
 

Dreamstime / MCT

Federal authorities have accused the owners of a Montgomery County-based dental conglomerate of running their businesses like a criminal enterprise — bilking millions of dollars from government health-care programs, illegally importing foreign workers, and endangering patients by implanting unapproved medical devices in their mouths for profit.

Brothers Bhaskar Savani, 56, of Ambler; Arun Savani, 55, of Blue Bell; and Niranjan Savani, 51, of Ambler, broke at least a dozen laws in their efforts to generate more than $316 million in profits between 2009 and last year, prosecutors said in a sprawling 102-page indictment unsealed Tuesday.

Investigators also accused the siblings of laundering their illicit proceeds through hundreds of bank accounts and embezzling more than $4 million from nearly three dozen companies to cover personal expenses like a Hawaiian vacation home, college tuition for their children, and utilities and tax payments on their homes.

The charges against the Savanis and nine codefendants — which include counts of racketeering conspiracy, visa and health-care fraud, money laundering, and conspiracy to distribute misbranded medical devices — are the result of a years-long investigation by nearly a dozen state and federal agencies into the empire the Savanis oversaw from a nondescript office park in Fort Washington.

Attorneys for the brothers balked at the government’s accusations, calling them a distortion of the Savani brothers’ companies and careers that now threatens to send them to prison for up to 20 years on the most serious count they face.

“The three brothers look forward to their day in court and cherish the concept that in this country that they have made their home, people are presumed innocent,” the lawyers said in a statement.

Viewed through a certain lens, the business empire the Savanis created since their arrival in the United States is an unquestionable success.

After emigrating from India, Bhaskar Savani, known as “Dr. B,” earned his dental degree from Temple University in 1995 and quickly set about building his practice into an empire.

Aside from his dental practices, he became an evangelist for the importation of Indian mangoes, persuading the U.S. Department of Agriculture in 2007 to lift a 18-year ban, and expanded into real estate, becoming one of the financial backers of a proposed indoor velodrome in Valley Forge in 2006.

Meanwhile, he brought on brothers Arun, to oversee financial affairs for the businesses, and Niranjan, a fellow dentist, to help him expand his core dental businesses into an empire.

Today, they oversee more than 50 dental practices across states including Pennsylvania, New Jersey, Iowa, and South Carolina and a bevy of associated companies focused on research and development of dental implant devices, employ more than 400 people, and serve thousands of patients each year, many from inner cities and other underserved areas where there are few practicing dentists.

Prosecutors say serving those low-income clients — especially those enrolled in government-funded health-care programs like Medicaid — was central to the Savani brothers’ grift.

Among other crimes alleged in the indictment, the Savanis are accused of relying on uncredentialed dentists to treat patients in violation of Medicaid rules.

Savani businesses allegedly required those dentists to falsely state that other licensed dental providers employed by their companies had performed treatments billed to Medicaid and required them to pay kickbacks to the doctors whose names they were using.

For instance, prosecutors said, between 2014 and 2018 Savani businesses submitted roughly 2,600 claims falsely stating that Niranjan Savani was the dentist performing procedures, when he was not even in the country at the time they were performed.

When authorities would catch on to the scheme and cancel Medicaid contracts with one Savani company, they’d have an employee open another — running it in name only — to land those contracts again, according to the indictment.

Between 2013 and last year, just one of those businesses — Allentown-based Smilekrafters Dental — earned roughly $80 million in Medicaid reimbursements under a contract it had fraudulently obtained, the document states.

But prosecutors said even as the Savanis were taking advantage of weaknesses in the Medicaid oversight, their companies were also exploiting foreign-born employees who worked for them.

The brothers recruited workers from India and elsewhere for jobs in the United States through a program meant to hire employees with specialized skills such as scientists, programmers, researchers, and analysts.

However, investigators say, many of the people for whom they helped secure visas ostensibly for jobs in the Savanis’ research-oriented companies, ended up in nonspecialized jobs running dental offices or as administrators being paid less than prevailing wage and required to kick back portions of their salaries to others in the companies.

The indictment paints one of the businesses run by the Savanis — Fort Washington-based EZ Biotek — as a front, filled with nonfunctioning lab equipment meant to fool immigration authorities when they would show up for periodic visits to verify those employees were working in active dental or chemistry research labs.

Still, some of the Savani companies’ research efforts were legitimate — including those at Fort Washington-based Osseolink USA, which starting in 2017 began developing a new kind of synthetic tooth implant for use in patients.

Though the implants had not yet received approval from the Food and Drug Administration, the brothers’ companies shipped prototypes in bags marked “not for human use” to several dental offices, where dentists employed by the brothers used them in the mouths of at least 18 patients, prosecutors said.

“Health care providers, who have a duty to practice in their patients’ best interests, are especially deceitful when they commit Medicaid fraud,” said Maureen R. Dixon, head of the U.S. Department of Health and Human Services’ Office of Inspector General.

In addition to the criminal charges, prosecutors are seeking forfeiture of some 27 properties linked to the Savanis and their businesses in Philadelphia, Montgomery, Delaware, Bucks, and Lehigh Counties as well as Iowa and Hawaii.

The brothers were released on bail pending trial after a brief initial court appearance Tuesday.

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FWA (MN)- In-home care provider investigated for $4M in Medicaid fraud

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]: Bridges MN is under investigation for billing for home care services on properties that it owns. Current estimate is at least $4M in fraudulent billing.

 
 

 
 

Clipped from: https://kstp.com/kstp-news/top-news/in-home-care-provider-investigated-for-4m-in-medicaid-fraud/

A St. Paul-based home health care company is being investigated by the Minnesota Attorney General’s Office for fraudulently overbilling the state’s Medicaid program, which is designed to support low-income residents and people with disabilities.

State investigators took computers, financial reports, rental agreements, and other documents from Bridges MN on Thursday, according to court documents filed last week. Authorities say they have already tracked $4 million in fraudulent billing over five years, with the possibility of more instances of fraud expected, according to a search warrant.

Bridges provides in-home care to more than 40 individuals across Minnesota, according to the warrant. Since 2016, the company has been reimbursed over $146 million for services provided to Medicaid recipients.

The Minnesota Department of Human Services previously revoked Bridges MN’s license after finding instances of maltreatment and non-compliance. State records show that the company is appealing that decision and has continued to operate.

DHS pieced together possible fraud after reviewing years of financial documents, daily care notes, and interviews with whistleblowers. The investigation comes after years of warnings from the agency, which told Bridges MN executives in 2019 the company was at risk of billing fraud if it provided services outside of the federally approved waiver plans.

 
 

Minnesota Attorney General Keith Ellison speaks during a press conference regarding the proposed merger between Fairview and Sanford Health on Nov. 22, 2022. (KSTP-TV)

After two years of notices, “Bridges continued to bill for services… well after receiving the first notice of non-compliance,” investigators with the Attorney General’s Office said.

No one from Bridges MN has been charged with a crime.

In a statement to 5 INVESTIGATES, an attorney for Bridges MN said the company “denies any wrongdoing and believes that the allegations in the search warrant affidavit will prove to be incorrect,” adding: “While we proactively address these allegations, we will continue to focus our complete attention on the clients and caregivers who look to us for support.”

Company executives are also facing accusations of billing for services on properties they own or have a financial stake in, which is illegal for “own-home” services in Minnesota.

The state investigation found Bridges MN was billing for services even when some of its residents were sleeping, going to online school, or going to church.

A case worker told the company in a January 2021 email: “it is fraudulent billing, and I can’t make that any different,” according to the warrant.

Asked by investigators about the documented overbilling, co-owner, Chief Financial Officer and Vice President of Finance Scott Loe told DHS that his company “does not consistently review supporting documentation to determine how to bill.” Loe also told investigators it would be “a good question” for other staffers, the warrant states.

Bridges MN is in the process of being sold to another company, Caregiver, which state officials said they believe will provide the same types of services. 

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FWA (NH)- Nashua man indicted on Medicaid fraud charges

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]: Ron Anderson got NEMT trips for fake medical visits. Where was he going? Is this a cheat code to use NEMT for Uber?

 
 

 
 

Clipped from: https://www.unionleader.com/news/courts/nashua-man-indicted-on-medicaid-fraud-charges/article_caabf5ed-7113-5550-a63a-36666297c4c8.html?block_id=849463

 
 

 
 

A Merrimack County Grand Jury has indicted a Nashua man on charges of Medicaid fraud, prosecutors said Tuesday.

Attorney General John M. Formella said in a news release Ronald Anderson, 46, of Nashua, has been indicted on charges of theft by deception and Medicaid fraud — false claims in connection with allegedly fraudulent claims for non-emergency medical transportation services.

The indictments allege that between July 7, 2020 and Feb. 20, 2022, Anderson fraudulently requested trips through the Medicaid non-emergency medical transportation program related to medical visits that did not exist.

Prosecutors claim Anderson acted with the intent to defraud New Hampshire Medicaid, receiving over $1,500 in Medicaid funds in connection with the alleged scheme.

Anderson will be arraigned in the Merrimack County Superior Court on a date to be determined.

The theft by deception charge carries a maximum penalty of 7 1/2 to 15 years in state prison and a $4,000 fine.

The maximum penalty for the Medicaid fraud charge is 3 1/2 to 7 years in jail and a $4,000 fine.

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FWA (MA)- DePuy Synthes, Inc. Agrees to Pay $9.75 Million to Settle Allegations Concerning Kickbacks Paid to Massachusetts Orthopedic Surgeon

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 J&J company is paying out $10M over using free implants and tools to a spinal surgeon that cause him to prefer their products whenever he submitted claims for Medicaid bennies.

 
 

 
 

Clipped from: https://www.justice.gov/opa/pr/depuy-synthes-inc-agrees-pay-975-million-settle-allegations-concerning-kickbacks-paid

Medical device manufacturer DePuy Synthes, Inc. (DePuy), a subsidiary of Johnson & Johnson, has agreed to pay $9.75 million to resolve allegations it violated the False Claims Act by paying kickbacks to an orthopedic surgeon based in Massachusetts to induce his use of DePuy products.

The settlement announced today resolves allegations that DePuy violated the Anti-Kickback Statute (AKS) and caused the submission of false or fraudulent claims to Medicare by paying the orthopedic surgeon kickbacks in the form of free spinal implants and tools for use in surgeries that the surgeon performed overseas to induce that surgeon to use DePuy products in surgeries performed in the United States. As part of the settlement, DePuy has admitted that from at least July 2013 through February 2018, DePuy, acting through certain former sales representatives, gave the Massachusetts surgeon thousands of dollars’ worth of free DePuy implants and instruments, including cages, rods, screws, plates, and surgical instrumentation, that the surgeon used to perform surgeries overseas for patients who were not federal health care beneficiaries. Of the $9.75 million to be paid by DePuy, approximately $7.23 million will be returned to the federal government, and approximately $2.52 million will be returned to Massachusetts, which jointly funded claims for surgeries involving DePuy devices that were submitted to the Massachusetts Medicaid program.

The AKS prohibits offering, paying, soliciting, or receiving remuneration to induce referrals of items or services covered by Medicare and other federally funded programs. The statute is intended to ensure that medical providers’ judgments are not compromised by improper financial incentives and are instead based on the best interests of their patients.

“Medical device manufacturers are prohibited from providing free items to induce a physician to use their devices,” said Principal Deputy Assistant Attorney General Brian M. Boynton, head of the Justice Department’s Civil Division. “When medical devices are used in surgical procedures, patients deserve to know that their device was chosen based on quality of care considerations and not on improper inducements from manufacturers.”

“Today the United States resolves allegations that DePuy provided over $100,000 worth of free product to a surgeon in order to secure and reward that physician’s continued business,” said U.S. Attorney Rachael S. Rollins for the District of Massachusetts. “Unlawful kickbacks can severely distort medical judgment as well as the market for medical devices. The millions of patients that depend on our health care system deserve untainted medical decisions. This settlement reflects our commitment to stamping out illegal kickbacks.”

“The American people, as both taxpayers and consumers, expect medical device manufacturers like DePuy to abide by relevant laws and regulations. When such health care companies provide illegal kickbacks in order to boost profits, their actions erode public confidence in the health care system, can compromise the patient-physician relationship, and waste government health program funding,” said Special Agent in Charge Phillip M. Coyne of the U.S. Department of Health and Human Services, Office of Inspector General (HHS-OIG). “In close cooperation with our law enforcement partners, we will continue to thoroughly investigate allegations of fraud to protect both federal health care programs and those served by them.”

“Today’s settlement makes it crystal clear that it is illegal for medical device companies to provide physicians with free medical products to win business and boost their bottom line through illegal kickback schemes,” said Special Agent in Charge Joseph R. Bonavolonta of the FBI Boston Division. “Every year, health care fraud costs taxpayers billions of dollars. It is not a victimless crime and this unscrupulous scheme orchestrated by DePuy is just one example of how the FBI and our partners are working hard every day to protect both patients and taxpayers.”

The lawsuit was originally filed under the qui tam or whistleblower provisions of the False Claims Act by Aleksej Gusakovs, who is a former sales representative for DePuy. Under those provisions, private parties, known as relators, can file an action on behalf of the United States and receive a portion of the recovery. The qui tam case is captioned United States et al. ex rel. John Doe v. Johnson & Johnson, et al., No. 17-cv-11502 (D. Mass.). As part of today’s resolution, Gusakovs will receive approximately $1.37 million.

The settlement was a result of a coordinated effort between the Civil Division’s Commercial Litigation Branch (Fraud Section) and the U.S. Attorney’s Office for the District of Massachusetts. The HHS-OIG provided investigative support.

The government’s pursuit of these matters illustrates the government’s emphasis on combating health care fraud. One of the most powerful tools in this effort is the False Claims Act. Tips and complaints from all sources about potential fraud, waste, abuse, and mismanagement can be reported to the Department of Health and Human Services, at 800HHSTIPS (800-447-8477).

The matter was handled by Senior Trial Counsel Benjamin C. Wei of the Civil Division and Assistant U.S. Attorneys Jessica Weber and Andrew Caffrey for the District of Massachusetts.

The claims resolved by the settlement are allegations only, and there has been no determination of liability.

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FWA(MA): Mother of disabled young man collected more than $120K while he was in jail, group home

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]: Jessica Parisella used her disabled to son to rack up $150k of bogus Medicaid claims for a family friend and for another ABA company.

 
 

 
 

Clipped from: https://www.salemnews.com/news/ag-mother-of-disabled-young-man-collected-more-than-120k-while-he-was-in-jail/article_0d89baea-9c33-11ed-9117-b3dd604771e7.html

BEVERLY — During the summer and fall of 2020, Jessica Parisella and Don Martel were fighting a plan to move Parisella’s disabled son to a group home.

Jonathan Jutras, now 22, had been a client of the Department of Developmental Services for years, receiving services from providers like Martel, whose company was being reimbursed by MassHealth, the state’s Medicaid program, for counseling Jutras.

His mother, meanwhile, acted as her son’s surrogate to collect MassHealth funds to pay a personal care assistant, a family friend.

After Jutras went to jail in 2019, those payments should have stopped, prosecutors say.

And that family friend? He lives on Nantucket, and, prosecutors say, agreed to sign blank time sheets for Parisella — who allegedly kept all of the money, totaling $120,648 — starting as far back as 2017.

Martel and his company, meanwhile, allegedly billed the state $35,045 for applied behavioral analysis services that he and his employees could not have provided to Jutras while he was in custody in 2019.

Parisella, 42, of Danvers, and Martel, 67, of Georgetown, both pleaded not guilty to charges of felony larceny and Medicaid fraud during their arraignments Tuesday in Salem Superior Court.

Both appeared in court in response to summonses that were sent after their indictments last month by an Essex County grand jury.

Because of that, Assistant Attorney General William Champlin did not seek bail for the pair — but did ask Judge Thomas Drechsler to set several conditions of release, including no contact with each other.

But both Parisella and Martel balked at some of the other proposed conditions — leading Drechsler to schedule a hearing next week on the issue.

Martel, who was deemed indigent and appointed a lawyer from the Committee for Public Counsel Services, did not want to agree to a condition that he not bill MassHealth for any services.

Nathaniel Spinney, the public defender, told the judge that such a prohibition would prevent Martel from earning money. “That is my client’s entire ability to work,” Spinney told the judge.

And Parisella objected to an order that she have no contact with the Nantucket man, Richard Jervah, while the case is pending.

Drechsler, citing the provisions of the state’s bail law, told lawyers for the pair and the prosecutor that he has no authority to impose conditions of release unless the defendants agree to them.

He also, however, told them that he would allow the attorney general’s office to change its request and seek bail for the pair.

He scheduled another hearing for Feb. 1.

Jutras suffers from several physical and mental disabilities, including a chronic lung condition and congenital hip issues, as well as being diagnosed on the autism spectrum, bipolar and attention deficit hyperactivity disorders. His mother told The Salem News in 2020 that Jutras functions at the level of someone half his age.

In 2019, he was arrested and charged with indecent assault and battery on three boys at a Beverly playground, after getting out of the Beverly apartment where his older brother was supposed to be watching him.

But his developmental issues made him incompetent to stand trial.

At the same time, officials were concerned that if released, Jutras could pose a danger.

His physical and mental health issues also made him vulnerable inside the jail, however, and his attorney sought and found a placement in a supervised forensic group home operated by Turning Point Inc. But Parisella and Martel objected to that plan, instead proposing that Martel be given funds to start a new program.

The dispute led to a months-long fight over guardianship.

Jutras was eventually moved to a supervised program in Boston, and later to a supervised group home, where he now lives. The charges against him remain open.

While their cases involve the same profoundly disabled young man, Champlin stressed that Parisella and Martel are not co-defendants and that their alleged schemes were separate.

Courts reporter Julie Manganis can be reached at 978-338-2521, by email at jmanganis@salemnews.com or on Twitter at @SNJulieManganis

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REFORM; STATE NEWS- Why One State Is Pushing Back Against Medicaid’s IMD Exclusion

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]: NY is looking to get a double waiver approach approved to transform how it uses IMDs to impact SUD and SMI outcomes.

 
 

Clipped from: https://bhbusiness.com/2023/01/20/why-one-state-is-pushing-back-against-medicaids-imd-exclusion/

New York state hopes to strengthen and remake state-managed behavioral health care by getting around the so-called IMD exclusion.

It’s doing so by securing federal Medicaid funds typically forbidden from covering facility-based behavioral health through its latest 1115 waiver amendment.

On Jan. 5, the Centers for Medicare & Medicaid Services (CMS) announced New York applied for a waiver to Medicaid’s now-antiquated institution for mental disease (IMD) exclusion. New York has asked for federal matching funds for Medicaid to be allowed to cover IMD services to address serious mental illness (SMI), substance use disorder (SUD) and serious emotional disturbance (SED) for adults and children.

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New York specifically is seeking matching funds to reimburse short-term inpatient, residential and other services for SMI and SUD by IMDs. The state is also applying for matching funds to help transition patients in state psychiatric facilities back to the community up to 30 days before their discharge.

“The objective of the demonstration is to transform the role of some state psychiatric inpatient facilities and [SUD] residential treatment facilities, improve care transitions and access to community-based treatment and support services, and improve health and behavioral health outcomes in individuals with chronic and/or [SMIs] by transforming selected (pilot site) state-run psychiatric hospitals, facilities, and campuses from long-term care institutions to community-based enhanced service delivery systems,” the 1115 waiver amendment proposal states.

Since the beginning of Medicaid in 1965, the Social Security Act forbade federal funds for Medicaid from covering treatment provided by facilities where 16 or more beds are dedicated to treating behavioral health issues of people aged 21 to 64.

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This move was intended to prevent states from offloading state psychiatric hospital costs on the federal government through the jointly funded and managed Medicaid program. It was also part of a political and regulatory retreat from treating behavioral health issues in large hospital-like settings, with champions of that movement including President John F. Kennedy.

The movement is sometimes referred to as deinstitutionalization.

However, some see the start of the deinstitutionalization movement as the start of the present psychiatric bed shortage, even within the federal government.

“There’s been an understanding in the past several years that this lack of federal funding contributes to high levels of unmet need,” Madeline Guth, senior policy analyst for Kaiser Family Foundation (KFF), told Behavioral Health Business. “The federal government has been providing some new mechanisms in the past few years for states to get an exception to this exclusion and get some federal financing for IMD services for non-elderly adults.”

The mechanisms, including the Medicaid 1115 waiver, allow states to secure some federal funding for certain IMD-related services.

Medicaid 1115 waivers, if approved by the federal government, allow states to experiment with different ways of implementing the Medicaid program.

There are three specific 1115 waiver benefit expansions that are related to behavioral health.

KFF, which tracks these waivers, found that 34 states have received approvals for an IMD exclusion payment exemption for SUDs. Additionally, 10 states have an exemption for mental health treatment, with 23 states having other exemptions for community-based health and behavioral health. 

Recent presidential administrations have enabled ways around the IMD exclusion through the 1115 waiver.

In July 2015, the Obama administration allowed for 1115 waivers to “develop a full continuum of care for individuals with SUD, including coverage for short-term residential treatment services not otherwise covered by Medicaid,” which included the IMD exclusion. 

The Trump administration announced in November 2019 that it approved the first-ever 1115 waiver related to IMD exclusion for SMIs and SEDs for adults and children.

Addressing the IMD exclusion did come up during the legislative work in 2022 that culminated in a sweeping behavioral health bill included in the omnibus funding bill passed just before Christmas. However, it was not included in the final bill that was signed into law on Dec. 29

While New York’s latest 1115 waiver application is not unprecedented, it does reflect a two-for-one application for two IMD exclusion exemptions — including both SMI and SUD funding.

Further, the New York waiver and the other waivers tracked by KFF show that states of all political leanings seek to address mental health via innovations to Medicaid.

Medicaid is the single largest payer of mental health services in the U.S.