Kusserow’s Corner: Highlights of April Medicaid Cases

In Scranton, PA, a pharmacist pleaded guilty to health care fraud charges for engaging in a scheme to defraud Blue Cross and Medicaid by submitting claims or causing claims for drugs allegedly prescribed when the prescriptions did not exist and for drugs not actually dispensed.

In Muskogee, Oklahoma, the Medical Center of Southeastern Oklahoma and its parent, Health Management Associates, Inc., agreed to pay $1,065,000 to the United States and $435,000 to the State of Oklahoma to resolve allegations they billed Medicaid for surgical procedures and related hospital services that were not medically necessary. The case originated by a qui tam whistleblower, who will receive $159,750 as part of today’s settlement.

In West Chester, PA, a woman who took care of her 22-year-old autistic daughter was found guilty of falsely billing Medicaid for un-provided services, keeping fraudulent time sheets, and pocketing money from the state and a school district that was intended for her daughter. She was sentenced to 12 years of probation, six months of which will be served under house arrest, and ordered to pay restitution of $160,000 to the state and $19,400 to the local school district for Medicaid fraud.

In Tennessee, the CRC Health Group agreed to a $9.25 million settlement to resolve TennCare fraud allegations regarding one of its substance-abuse rehabilitation facilities. The practice was accused of exceeding its state-licensed patient capacity and using third-party pharmacies to fraudulently double-bill the TennCare program.

In New Orleans, 20 personal care attendants servicing a senior residential facility were arrested on allegations of submitting false Medicaid payment claims for un-provided services. The attendants, who were from four providers, allegedly filed a total of $150,000 worth of fraudulent claims over approximately one year.

A resident of Orange County, VA, was sentenced to 20 years in prison, with 17 years suspended, for defrauding the Medicaid program out of $18,375.30. He lied about a supposed debilitating medical condition, hired personal care aides, and submitted fraudulent time sheets for health care services the aides did not provide, and then received kickbacks from payments the aides received from Medicaid. Three of the personal care aides have also been convicted in the fraud case and await sentencing.

A North Dakota resident pleaded guilty, and was ordered to pay approximately $37,000 in restitution and about $37,000 in civil penalties to a charge of making false statements to secure Medicaid benefits. He admitted to lying about his mother’s assets and finances so she would qualify for Medicaid benefits upon entering a nursing home.

In Tallahassee, FL, a woman was arrested for Medicaid fraud for allegedly received more than $8,000 for personal care services provided to a disabled adult, which were actually never provided.

A New Jersey-based pharmaceutical company agreed to pay $10 million to resolve allegations of Medicaid fraud in Texas. The company is accused of knowingly inflating its drug prices, which led to higher reimbursement rates from the Medicaid program.

In Alton, IL, a medical doctor who operated a clinic was sentenced to 12 months in prison, a $5,000 fine, a $1,500 special assessment, restitution to Medicaid of $397.48, and two years of supervision following release from prison. He pleaded guilty to the 15 felony counts of an indictment which charged health care fraud against the Illinois Medicaid program and illegal distribution of Schedule III controlled substances (Hydrocodone) and Schedule IV controlled substances (Xanax®) by prescribing outside the usual course of professional conduct and without legitimate medical purpose.

In Kansas City, KS, a woman working as a personal care attendant was indicted on a charge of six counts of fraud against the Medicaid program that paid more than $587,000 based on fraudulent bills she submitted.

In Madison, WI, a man was sentenced for Medicaid fraud. The judge imposed and stayed sentences of imprisonment for three years, to be served concurrently to each other and consecutive to any other sentences, comprising 18 months initial confinement and 18 months extended supervision. The judge then placed him on probation for two years, with conditions of six months in jail, alcohol or other drug abuse assessment, anger management treatment, participation in a criminal thinking program, preclusion as a payee for any government public assistance program, and payment of $3,546 restitution.

Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

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Copyright © 2014 Strategic Management Services, LLC. Published with permission.