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MCOs (LA)- State officials scrutinize BCBS Louisiana sale to Elevance

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]: State senators and the AG want to know more about how the proceeds of the sale will work.

 
 

 
 

Clipped from: https://www.beckerspayer.com/m-and-a/state-officials-scrutinize-bcbs-louisiana-sale-to-elevance.html

Three Louisiana state senators and the attorney general are calling for a delay of Blue Cross Blue Shield of Louisiana’s sale to Elevance Health, nola.com reported Aug. 16. 

The senators’ call for a delay stemmed from reports commissioned by the state’s insurance commission that was released shortly before a six-hour legislative hearing on the deal, according to the report. 

The independent reports from actuarial firms hired by the commission questioned how BCBS plans to structure the deal, according to the report. 

BCBS has proposed giving a fraction of the sale proceeds to policyholders, according to the report. That group includes employers and some beneficiaries who have purchased plans individually, but not every person in the state covered by the payer. Policyholders would receive about $307 million, which amounts to about $3,000 per policyholder. The rest would go to a nonprofit foundation called Accelerate Louisiana that would be created as a result from the sale.  

Louisiana Attorney General Jeff Landry said he does not have a position on the deal but has concerns about how it could affect premiums, how proceeds will be split between policyholders and a foundation that will be formed from the sale and whether the foundation is in the best interest of state residents, according to nola.com. He also said he opened an investigation into the deal for potential antitrust violations. 

BCBS Louisiana CEO Steve Udvarhelyi, MD, defended the deal before lawmakers, saying it is the best way to bring technology, better pharmacy benefits and new programs to Blue Cross beneficiaries. He said there will be no changes or layoffs, “but if we do not do something now to secure our future, the forces at play in the marketplace, the inevitable forces of consolidation, will happen and we will have to consolidate from a position of weakness.”

Elevance announced plans to acquire BCBS Louisiana in January. The company will become a for-profit subsidiary of Elevance if the deal is approved.  

The deal needs approval from the state insurance commissioner along with two-thirds of BCBS policyholders, according to the report. 

Subscribe to the following topics: blue cross blue shield of louisianaelevance healthaccelerate louisianasteve udvarhely

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MCOs (GA)- CareSource Georgia rolls out mobile clinics to help Medicaid recipients maintain health coverage

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]: CareSource is sending in Wellness on Wheels to places where the data shows members are missing wellness visits.

 
 

 
 

Clipped from: https://georgiarecorder.com/brief/caresource-georgia-rolls-out-mobile-clinics-to-help-medicaid-recipients-maintain-health-coverage/

 
 

Jason Bearden, president of CareSource Georgia, talks about how the care management organization is using a mobile clinic to reach people at risk of losing their Medicaid coverage during the unwinding. Jill Nolin/Georgia Recorder

The state has leaned on its three care management organizations as part of its strategy to alert all 2.8 million Medicaid enrollees of the return of the renewal process, which the federal government had paused during the pandemic.

And on Wednesday, one of them – CareSource Georgia – publicly launched part of its plan to reach its members: Go to them.

CareSource Georgia says it is partnering with providers across the state to use mobile clinics, dubbed Wellness on Wheels, to help spread the word about what people need to do to keep their Medicaid coverage.

Laptops are on board to help people update their information in the state system and go ahead and renew their coverage if it’s their turn to go through the process. The state is handling the renewals in groups one month at a time.

An alarming number of people have been losing their Medicaid coverage during the unwinding for procedural reasons – like not responding to renewal notices in time – and not because they are no longer eligible.

“You can communicate, advertise all day, but to have tools and the resources right there at their fingertips to get it done – there’s nothing like it,” said Jason Bearden, president of CareSource Georgia.

So far, CareSource Georgia and its partners have five such rolling mobile clinics throughout the state. Wednesday’s press conference outside the state Capitol featured Atlanta-based Eastchester Family Services.

Dr. Seema Csukas, chief medical officer at CareSource Georgia, said the program targets “medical deserts” and brings medical and behavioral health providers to those areas. Data showing where members have missed routine wellness checks helps determine destinations.

“We’re looking for areas where there are a lot of gaps, and that’s where we want to set up shop,” Csukas said.

If someone is no longer eligible for Medicaid, Bearden said CareSource staffers are trying to help educate members on their other options, including a new Medicaid program launched in July.

Georgia Pathways to Coverage is an option for low-income Georgians who complete 80 hours of work or qualifying activity each month to gain and keep coverage. The state has planned for as many as 100,000 people to enroll in the program, but the new initiative is off to a slow start. Just 265 people signed up in the first month.

Bearden said about 50 CareSource members signed up for Pathways, which he called “critical.”

“If it is determined that they’re above – unfortunately – the Medicaid eligibility lines, the first stop is ‘Hey, let’s look at Pathways. Are you eligible for Pathways? Are you in school? Are you doing volunteer work? Are you working? Part time or full time, that might qualify you for Pathways,'” Bearden said.

“So, that is a big part of the continuum,” he said. 

 
 

Ariel Esteves (left), vice president of clinical operations with CareSource, gives a tour of the exam room on board a mobile clinic. CareSource Georgia and its partner Eastchester Family Services are using the clinic to help people keep their Medicaid coverage. Jill Nolin/Georgia Recorder

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FWA (CA)- Office of Public Affairs | Health Care Provider Agrees to Pay $5 Million for Alleged False Claims to California’s Medicaid Program

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]: Another facility got caught helping an MCO inflate its MLR.

 
 

 
 

Clipped from: https://www.justice.gov/opa/pr/health-care-provider-agrees-pay-5-million-alleged-false-claims-californias-medicaid-program

Lompoc Valley Medical Center (LVMC), a California Health Care District that operates multiple health care providers, including a hospital and several clinics, in Lompoc, California, has agreed to pay $5 million to resolve allegations that it violated the False Claims Act and the California False Claims Act by causing the submission of false claims to California’s Medicaid program (Medi-Cal) related to Medicaid Adult Expansion under the Patient Protection and Affordable Care Act (ACA).

Pursuant to the ACA, beginning in January 2014, Medi-Cal was expanded to cover the previously uninsured “Adult Expansion” population – adults between the ages of 19 and 64 without dependent children with annual incomes up to 133% of the federal poverty level. The federal government fully funded the expansion coverage for the first three years of the program. Under contracts with California’s Department of Health Care Services (DHCS), Santa Barbara San Luis Obispo Regional Health Authority, doing business as CenCal Health (CenCal), arranges for the provision of health care services as a county organized health system under Medi-Cal in Santa Barbara County and San Luis Obispo County, California, by contracting with providers such as LVMC to provide health care services to Medi-Cal patients. Under its contractual arrangement with DHCS, CenCal received funding to serve the Adult Expansion population.  If CenCal did not spend at least 85% of the funds it received for the Adult Expansion population on “allowed medical expenses,” CenCal was required to pay back to the state the difference between 85% and what it actually spent. California, in turn, was required to return that amount to the federal government.

The settlement resolves allegations that LVMC knowingly caused the submission of false claims to Medi-Cal pursuant to agreements executed by LVMC with CenCal for “Enhanced Services” that LVMC purportedly provided to Adult Expansion Medi-Cal members between Jan. 1, 2014, and June 30, 2016. The United States and California alleged that LVMC claimed and received payments pursuant to those agreements that were not for “allowed medical expenses” permissible under the contract between DHCS and CenCal; were pre-determined amounts that did not reflect the fair market value of any Enhanced Services provided by LVMC; and/or the Enhanced Services were duplicative of services already required to be rendered by LVMC. The United States and California further alleged that the payments were unlawful gifts of public funds in violation of the California Constitution.

“The Medicaid program provides critical health care services to those most in need,” said Principal Deputy Assistant Attorney General Brian M. Boynton, head of the Justice Department’s Civil Division. “We will hold providers accountable when they knowingly divert Medicaid funds from their intended purpose.”

“Millions of Americans depend on the Medicaid program for essential health care services,” said U.S. Attorney Martin Estrada for the Central District of California. “When providers cheat the system, they cheat us all.  My office will not stand for this type of misconduct.  We will ensure that the nearly $100 million recovered in this case goes to those in need and not to unscrupulous providers.”

“Federal health care programs are intended to ensure that millions of Americans have access to high quality, medically necessary care,” said Special Agent in Charge Timothy B. DeFrancesca of the Department of Health and Human Services Office of Inspector General (HHS-OIG). “Protecting federal health care funds from fraud, waste, and abuse is at the center of HHS-OIG’s mission, and we are committed to ensuring that these valuable resources are available to patients as intended.”

“Medi-Cal supports millions of Californians by providing for the critical healthcare they rely on every day,” said California Attorney General Robert Bonta. “When providers misuse Medi-Cal funding, they siphon away much-needed resources from vulnerable, deserving patients.  My office always stands ready to partner with the U.S. Department of Justice to hold such perpetrators accountable.  The California Department of Justice is committed to protecting the integrity of the Medi-Cal program against those who may seek to abuse it.”

The civil settlement includes the resolution of claims brought under the qui tam or whistleblower provisions of the False Claims Act by Julio Bordas, CenCal’s former medical director. Under the act, a private party can file an action on behalf of the United States and receive a portion of any recovery. The qui tam case is captioned United States and State of California ex rel. Bordas v. Lompoc Valley Medical Center, et al., No. 15-cv-09834 (C.D. Cal.).  Mr. Bordas will receive approximately $950,000 as his share of the federal recovery.

This settlement brings the United States’ total recovery in the matter to $95.5 million.  CenCal, Cottage Health System, Sansum Clinic and Community Health Centers of the Central Coast previously paid $68 million, and Dignity Health and Twin Cities Community Hospital and Sierra Vista Regional Medical Center, two subsidiaries of Tenet Healthcare Corporation, previously paid $22.5 million, to settle similar False Claims Act allegations. 

The resolution obtained in this matter was the result of a coordinated effort between the Justice Department’s Civil Division, Commercial Litigation Branch, Fraud Section, the U.S. Attorney’s Office for the Central District of California, and the California Department of Justice, with assistance from HHS-OIG and DHCS.

The investigation of this matter illustrates the government’s emphasis on combating healthcare 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 800-HHS-TIPS (800-447-8477).

Trial Attorneys Mary Beth Hickcox-Howard and Tiffany L. Ho of the Civil Division’s Commercial Litigation Branch, Fraud Section and Assistant U.S. Attorney Jack D. Ross for the Central District of California handled this case.

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

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FWA (MN)- Charges filed against 18 people in alleged $9.5 million Medicaid caregiver 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]: Pretty big for a personal care assistant scheme.

 
 

 
 

Clipped from: https://kstp.com/kstp-news/local-news/charges-filed-against-18-people-in-alleged-9-5-million-medicaid-caregiver-fraud-case/

Owners and managers of a personal care assistant (PCA) company are facing criminal charges related to a scheme to defraud the Minnesota Medical Assitance Program (Medicaid) out of about $9.5 million.

The case is the largest Medicaid fraud prosecution charged by the Minnesota Attorney General’s Office and its Minnesota Medicaid Fraud Control Unit, the attorney’s office says.

Court documents show the owners of the company called MN Professional — 58-year-old Abdikarimm Mohamed and 53-year-old Ahmed Nur — are each charged with one count of racketeering, one count of engaging in the business of concealing criminal proceeds and 11 counts of aiding and abetting theft by swindle of an amount larger than $35,000. Three managers in the company, 55-year-old Abubakar Ahmed, 60-year-old Ali Elmi and 44-year-old Omar Dirie, are charged with the same crimes.

Prosecutors say that the company billed Medicaid for services that were not provided, which amounted to more than $1.6 million. MN Professional also allegedly provided services without a nurse or qualified professional (QP) present for at least 120 clients, which added up to more than $7.8 million. Minnesota law mandates that PCA services must be supervised by a QP in order to be eligible for payment from Medicaid.

“Minnesotans who receive Medical Assistance have a right to expect they’ll receive all the care, dignity, and respect they’re entitled to,” Minnesota Attorney General Keith Ellison said in a prepared statement. “Minnesotans trying to afford their lives have a right to expect that every one of their tax dollars will be spent properly and legally. People who commit Medicaid fraud violate both of those rights. My office is working aggressively to hold these and all offenders accountable — and we will keep doing so.”

As of Wednesday afternoon, a total of 18 people are charged with crimes revealed in the state’s investigation, including recruiters, an office manager and PCAs. Those charges include 32 counts of aiding and abetting portions of the agency’s fraud and one count of identity theft. There were also six other people who were previously charged and all but one of them pleaded guilty according to a news release from the AG’s office.

RELATED: 4 charged with defrauding Medicaid program of over $900K

The complaint states that the crimes were concealed through “an elaborate cash-checking scheme.” The checks were apparently written in the names of PCAs whose identities were used to bill fraudulently, and the suspects kept the cash for themselves. This caused some PCAs to get artificially inflated W2s that showed they received wages from MN Professional that they did not.

Prosecutors say Mohamed and Nur both fraudulently listed their wives as board members and consultants at the company and paid them hundreds of thousands of dollars under the guise of paying their salaries.

The suspects are also accused of recruiting clients and PCAs with the intent of using them to defraud the Medicaid program and falsify information to get loans related to COVID-19 relief.

The AG’s office says more charges are expected to be filed against others as the investigation continues.

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WA (MI)- Eastern District of Michigan | Michigan Doctor to Pay $6.5 million to Resolve False Claims Act Allegations

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]: Another bogus drug testing scam, and a whistleblower that made out pretty good.

 
 

 
 

Clipped from: https://www.justice.gov/usao-edmi/pr/michigan-doctor-pay-65-million-resolve-false-claims-act-allegations

DETROIT – A Michigan interventional pain management specialist, Rajendra Bothra, M.D., and two medical entities that he owned and operated, The Pain Center USA, PLLC, and Interventional Pain Center, PLLC, (collectively, “Defendants”) have agreed to pay $6,500,000 to resolve claims that they violated the federal False Claims Act, United States Attorney Dawn N. Ison announced today.

The settlement announced today resolves allegations that from January 1, 2015, to December 31, 2018, Defendants billed Medicare and Medicaid for excessive and medically unnecessary presumptive and definitive urine drug tests that were not relevant to their patients’ diagnosis or treatment, along with additional laboratory charges that were not separately billable with the urine drug tests. Additionally, Defendants are alleged to have billed Medicare and Medicaid for medically unnecessary moderate sedation services that were routinely performed in conjunction with interventional pain management procedures that did not require moderate sedation services. The government also alleges that Defendants frequently charged Medicare and Medicaid for expensive back braces that were medically unnecessary or otherwise ineligible for reimbursement.

“Our office remains steadfast in our commitment to protect federal health care programs, their beneficiaries, and taxpayers from fraud and abuse,” said U.S. Attorney Ison.

“This settlement underscores the important role that medical providers have in ensuring that the claims submitted to Federal health care programs are medically necessary,” said Mario M. Pinto, Special Agent in Charge of the U.S. Department of Health and Human Services, Office of Inspector General. “Our office remains committed to working with our law enforcement partners to ensure that health care providers who violate the False Claims Act are held accountable.”

“When healthcare providers manipulate the Medicaid and Medicare systems, it wastes resources meant to help those in need,” said Devin J. Kowalski, Acting Special Agent in Charge of the FBI’s Detroit Field Office. “This settlement brings to bear some economic justice by requiring those who orchestrated the fraud scheme to pay for their actions.”

The civil settlement includes the resolution of claims in two separate lawsuits brought by relators under the qui tam or whistleblower provisions of the False Claims Act. Under these provisions, a private party can file an action on behalf of the United States and receive a portion of any recovery. The two qui tam cases are captioned United States ex rel. Ronald Kufner et al. vs. The Pain Center USA PLLC, et al., No. 2:17-cv-11644 (E.D. Mich.) and United States ex rel. Hersh Patel vs. Interventional Pain Center, et al, No. 2:18-cv-12728 (E.D. Mich.). As part of the settlement, the relators will receive a combined payment in the amount of

$1,267,500.

The resolution obtained in this matter was the result of a coordinated effort between the U.S. Attorney’s Office for the Eastern District of Michigan, and the Michigan Attorney General’s Health Care Fraud Division, with assistance from the U.S. Department of Health and Human Services, Office of Inspector General, and the Federal Bureau of Investigations. Assistant U.S. Attorney Carolyn Bell Harbin represented the United States in this matter.

The investigation and resolution of this matter 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 800- HHS-TIPS (800-447-8477).

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FWA (CT)- District of Connecticut | Somers Man Pleads Guilty to Charge Stemming from Medicaid Fraud Scheme Justice

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 provider let another provider use their billing ID- for a 25% cut. You paid $338k for it.

 
 

 
 

Clipped from: https://www.justice.gov/usao-ct/pr/somers-man-pleads-guilty-charge-stemming-medicaid-fraud-scheme

Vanessa Roberts Avery, United States Attorney for the District of Connecticut, Roberto Coviello, Special Agent in Charge of the U.S. Department of Health and Human Services, and Robert Fuller, Special Agent in Charge of the New Haven Division of the Federal Bureau of Investigation, today announced that DENNIS TOMCZAK, 73, of Somers, has pleaded guilty in federal court to a false statement offense stemming from his role in a Medicaid fraud scheme.

According to court documents and statements made in court, Tomczak, a state-licensed alcohol and drug abuse counselor, offered substance abuse treatment and related counseling services through his business, Pathway to Peace, LLC.  Tomczak accepted Medicaid insurance and cash payments for his services.

In 2019, a medical provider asked Tomczak to use his own provider number to bill Medicaid for patients that the provider was allegedly seeing for psychotherapy sessions.  In exchange, Tomczak would retain 25 percent of the Medicaid claims paid and he would turn over 75 percent of the payments to the provider.  Tomczak agreed to do so, and from approximately April 2019 through October 2022, based upon a spreadsheet provided to him by the provider, Tomczak billed Medicaid for psychotherapy and related services allegedly rendered by the provider as if Tomczak had personally rendered those services himself.  Tomczak never met any of the provider’s clients and did not review records and treatment notes for any services allegedly rendered by the provider.

Through this scheme, Medicaid paid Tomczak approximately $338,427.11 for approximately 53 clients that the provider had allegedly treated.  Per his agreement with the provider, Tomczak retained approximately $84,000 of the claims money received from Medicaid.

On August 21, 2023, Tomczak waived his right to be indicted and pleaded guilty before U.S. District Judge Kari A. Dooley in Bridgeport to one count of making a false statement relating to a health care matter, an offense that carries a maximum term of imprisonment of five years.  Judge Dooley scheduled sentencing for November 13.

Tomczak is released on bond pending sentencing.

This ongoing investigation is being conducted by the Office of the Inspector General of the U.S. Department of Health and Human Services (HHS-OIG), and the Federal Bureau of Investigation.  The case is being prosecuted by Assistant U.S. Attorney Sarah P. Karwan.

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FWA (NY)- DiNapoli: Three Arrested in Connection With Over $1 Million Medicaid Transportation 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]: Another bogus NEMT scheme. And another story of Medicaid members taking kickbacks to make it happen.

 
 

 
 

Clipped from: https://www.osc.state.ny.us/press/releases/2023/08/dinapoli-three-arrested-connection-over-1-million-medicaid-transportation-fraud-scheme

Arrests Follow Joint Investigation Between the State Comptroller’s Office, the Otsego County District Attorney, the Otsego County Sheriff’s Office, the Oneonta Police Department and the U.S. Department of Health and Human Services – Office of Inspector General

August 28, 2023

Three principals of Phinaliz Communications LLC were arrested in connection with a long-running scheme to steal over $1 million from the Medicaid program by billing for fake transportation services, duplicating and inflating costs, and paying kickbacks to Medicaid recipients, State Comptroller Thomas P. DiNapoli announced today on behalf of the joint state, local and federal investigating agencies. The three defendants, Philip Mtui, Mbaga Kaiza, and Tony Taylor, were arrested last Thursday.

“The defendants allegedly engaged in a systematic scam to defraud the Medicaid program of millions of dollars,” said New York State Comptroller Thomas P. DiNapoli. “Medicaid fraud impacts us all and diverts money from those truly in need. Thanks to the partnership between my office, Otsego County District Attorney Muehl, Otsego County Sheriff Devlin, Oneonta Chief of Police Witzenburg and the HHS-OIG, this fraud was uncovered and now these defendants will be held accountable.”

“In initiating this investigation, we immediately realized its impact and importance and are therefore appreciative of the support we received,” Otsego County Sheriff Richard J. Devlin Jr. said. “We commend our local, state, law enforcement and administrative partners, especially Paul White of Viapath Technologies, for their tireless dedication to a comprehensive and thorough investigation. Collectively, this effort identified, disrupted, and dismantled criminal activity that affected every citizen and taxpayer of New York state.”

“The disruption of this criminal behavior and associated kickbacks for fraudulent charges has an impact beyond theft,” Oneonta Police Chief Christopher Witzenberg said. “The kickbacks were undoubtably used to fuel substance abuse issues for vulnerable people, resulting in a host of other complications in our community. It is not just an example of theft and fraud from the public, but the exploitation of people for profit. I would like to thank the Otsego County District Attorney’s Office and the Otsego County Sheriff’s office, as well as the other partners in this investigation, for their cooperation and coordination.”

“HHS-OIG continuously works with our law enforcement partners to investigate individuals who are believed to have exploited federally funded health care programs for their own greed,” said Naomi Gruchacz, Special Agent in Charge with the U.S. Department of Health and Human Services, Office of Inspector General (HHS-OIG). “Individuals and entities that participate in federal and state health care systems are required to obey the laws meant to preserve the integrity of program funds and the provision of appropriate, quality services to patients.”

Phinaliz Communications, based in Otsego County, is enrolled in the Medicaid program as a participating transportation provider for Medicaid recipients. Under Medicaid regulations, patients may use transportation services for legitimate appointments which are billed to the Medicaid program by the provider.

Phinaliz is owned by Mechanicville resident Mtui, 46. Kaiza, 47, is the operational manager and is also a New York state resident. Taylor, 42, is a manager, dispatcher and driver.

The joint investigation revealed that over a four-year period, Mtui and Kaiza defrauded the Medicaid program by claiming payment for rides that never occurred, and double, triple, or quadruple billing for rides that did occur. Investigators found that Medicaid enrollees were being paid kickbacks by the company to use their service and provide their information to facilitate the alleged crimes.

The crime ring was exposed through a multi-year investigation by state, local and federal authorities involving extensive surveillance and the execution of a search warrant on company headquarters. These are the first round of arrests. The investigation is continuing.

Mtui and Kaiza were arraigned in Oneonta City Court on one count of Grand Larceny in the First Degree, theft of over $1 million. Mtui and Kaiza both were held on $250,000 bail. Taylor was arrested on one count of conspiracy in the sixth degree related to the kickback scheme and will be arraigned on Sept. 19.

The Otsego County Department of Probation, the Otsego County Department of Social Services, the New York State Department of Motor Vehicles, the Oneida County Sheriff’s Office, the Saratoga County Sheriff’s Office and the East Greenbush Police Department also assisted in the investigation.

The charges filed in this case are merely accusations and the defendants are presumed innocent unless and until proven guilty in a court of law.

Since taking office in 2007, DiNapoli has committed to fighting public corruption and encourages the public to help fight fraud and abuse. New Yorkers can report allegations of fraud involving taxpayer money by calling the toll-free Fraud Hotline at 1-888-672-4555, by filing a complaint online at https://www.osc.state.ny.us/investigations, or by mailing a complaint to: Office of the State Comptroller, Division of Investigations, 8th Floor, 110 State St., Albany, NY 12236.

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FWA (DC)- District of South Carolina | Greenville Woman Pleads Guilty to Making Fraudulent Statements to Medicaid in Connection with the Delivery of Autism Spectrum Disorder Services

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]: $900k stolen for a bogus ABA scam.

 
 

 
 

Clipped from: https://www.justice.gov/usao-sc/pr/greenville-woman-pleads-guilty-making-fraudulent-statements-medicaid-connection-delivery

COLUMBIA, SOUTH CAROLINA —Nina Bourret, 41, of Greenville, pleaded guilty in federal court to making false and fraudulent statements on claims submitted to Medicaid. 

Evidence obtained in the investigation revealed that Bourret was an owner of Agapi Behavior Consultants, Inc., which provided Applied Behavior Analysis therapy to treat Autism Spectrum Disorder.  From February 2021 to December 2022, Bourret submitted electronic claims to Medicaid on behalf of Agapi falsely and fraudulently certifying that services had been rendered and/or certifying that services had been rendered in excess of what was actually provided to the beneficiary.

The investigation has revealed Bourret and Agapi submitted claims to Medicaid that contained false and fraudulent statements in excess of $900,000.00.

Bourret faces a maximum penalty of 5 years in federal prison. She also faces a fine of up to $250,000, restitution, and 3 years of supervision to follow the term of imprisonment.  Senior United States District Judge Henry Michael Herlong, Jr. accepted the guilty plea and will sentence Bourret after receiving and reviewing a sentencing report prepared by the U.S. Probation Office.

The case was investigated by the Federal Bureau of Investigation, the Department of Health and Human Services – Office of the Inspector General, and the South Carolina Attorney General’s Medicaid Fraud Control Unit.  Assistant U.S. Attorney Amy Bower is prosecuting the case.

###

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PHE- Florida Medicaid eligibility: Lawsuit seeks to halt state from terminating some residents’ benefits

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]: And so it begins.

 
 

 
 

Clipped from: https://www.cnn.com/2023/08/22/politics/florida-medicaid-eligibility-lawsuit/index.html

CNN  — 

Two consumer advocacy groups filed a lawsuit in a Florida federal court Tuesday seeking to halt the state’s termination of residents’ Medicaid benefits.

The suit is the first in the nation to challenge states’ resumption of reviewing Medicaid enrollees’ eligibility and dropping those deemed no longer qualified. The process, which Congress had suspended for three years during the Covid-19 pandemic, restarted as early as April, depending on the state.

The Florida Health Justice Project and the National Health Law Program filed the lawsuit on behalf of three Floridians in US District Court in Jacksonville against the state’s Agency for Health Care Administration and the Department of Children and Families. The residents are a 25-year-old woman and her 2-year-old daughter, who has cystic fibrosis, as well as a 1-year-old girl.

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The plaintiffs argue that the notices the agencies are sending to inform enrollees that they are no longer eligible are confusing and don’t provide sufficient explanation as to why they are losing coverage.

“As a result, Plaintiffs and class members are losing Medicaid coverage without meaningful and adequate notice, leaving them unable to understand the agency’s decision, properly decide whether and how to contest their loss of Medicaid coverage, or plan for a smooth transition of coverage that minimizes disruptions in necessary care,” the complaint reads. “Without Medicaid coverage, Plaintiffs are unable to obtain care they need, including prescription drugs, children’s vaccinations, and post-partum care.”

The advocates are asking the court to require the state to stop terminating enrollees until the agencies provide adequate notice and an opportunity for a pre-termination fair hearing.

Mallory McManus, deputy chief of staff for the Department of Children and Families, called the lawsuit “baseless.” While she said the state cannot comment on pending litigation, she said the letters to recipients are “legally sufficient.”

The federal Centers for Medicare and Medicaid Services “approved the Department’s redetermination plan based on their regulations. There are multiple steps in the eligibility determination process and the final letter is just one of multiple communications from the Department,” said McManus, adding that the agency “continues to lead on Medicaid determinations and being fiscally responsible.”

The Agency for Health Care Administration did not immediately return a request for comment.

Nearly 183,000 Floridians have been issued notices saying they no longer qualify for Medicaid, according to the lawsuit. Hundreds of thousands more will have their coverage reviewed in the coming year.

In addition to those determined ineligible, nearly 226,000 were dropped for so-called procedural reasons, typically because enrollees did not complete the renewal application, according to KFF, formerly the Kaiser Family Foundation. This often happens because it may have been sent to an old address, it was difficult to understand or it wasn’t returned by the deadline.

Nearly 898,000 Florida residents have had their coverage renewed, according to KFF.

Nationwide, more than 5.2 million people have been disenrolled since the so-called Medicaid unwinding began in the spring, according to KFF. Nearly three-quarters of those who have lost coverage were dropped for procedural reasons.

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PHE- Arkansas Medicaid recipients share concerns with federal and state officials

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]: Prediction- there will be 10 lawsuits by Labor Day, and the next one will come out of AR. May be able to predict which law firm within a week depending on patterns we see in the next few.

 
 

 
 

Clipped from: https://arkansasadvocate.com/2023/08/22/arkansas-medicaid-recipients-share-concerns-with-federal-and-state-officials/

Protesters want the state to pause its ongoing disenrollment of Medicaid recipients whose eligibility paperwork hasn’t been received

 
 

Protesters march from Woodlane Street to the Arkansas Capitol on Tuesday, Aug. 22, 2023, to deliver a letter to Gov. Sarah Huckabee Sanders’ office detailing the difficulties they have had with the state’s Medicaid program. (Tess Vrbin/Arkansas Advocate)

A group of Arkansans on Tuesday petitioned state and federal officials to intervene in the state’s administration of Medicaid, which they have repeatedly said needs improvement.

Arkansas Community Organizations held the latest of several protests this year airing Medicaid recipients’ complaints, including difficulties ensuring that the state Department of Human Services has accurately recorded or updated people’s income and contact information.

The organizers wrote a letter to the federal Centers for Medicare and Medicaid Services, asking its division that administers Medicaid and the Children’s Health Insurance Program (CHIP) to work with Arkansas officials on improving the state’s administration of benefits.

Medicaid is a joint federal and state health care program for people with disabilities and those who meet certain income thresholds. The program covers about 90 million Americans, including more than 900,000 Arkansans.

The letter to CMS lists changes to Medicaid that recipients have repeatedly said would make services more accessible to them and others.

Examples include using plain language in written notices that DHS sends to Medicaid clients and staffing DHS’ county offices with employees who fully understand the rules and criteria of Medicaid’s many programs.

The protesters met outside the Victory Building across the street from the state Capitol building, carrying signs that said “Educate your employees” and “Try harder to reach everyone,” among other things.

Rally co-organizer Joyce Means said she is eligible for Medicaid coverage under the federal Pickle Amendment of 1977. The amendment created a class of Medicaid eligibility for people who receive Social Security benefits but exceed the income limit for Supplemental Security Income, which is aimed at people with disabilities and low-income older adults.

“Tell me why I had to go to DHS to explain to them what the Pickle Amendment is,” Means said. “I had a worker tell me he’s worked there for over four years and this was his first time hearing of this.”

Additionally, some adults in Arkansas who receive Medicare coverage due to their older age have been receiving smaller Social Security checks lately, Means said.

“Medicaid pays the premiums for Medicare, so when that happens, it comes out of the recipient’s [Social Security] check, and some people are already low-income or on disability,” Means said.

Post-pandemic unwinding

Organizers’ letter to CMS also requests that Arkansas pause its ongoing project of disenrolling Medicaid recipients whose coverage was extended by the federal government during the COVID-19 pandemic. The extension ended in May, and states began “unwinding” it in April.

Since then, DHS has disenrolled more than 144,000 Arkansans from Medicaid after not receiving required eligibility information, in addition to the clients who asked to be disenrolled or made too much money to be eligible.

Arkansas Community Organizations have repeatedly expressed concern that some Arkansans who are still eligible for Medicaid could lose their coverage or have already lost it due to bureaucratic hurdles.

Most states have a full year to conduct the “unwinding,” but Arkansas has six months, as required by a 2021 state law. Arkansas Medicaid recipients asked in March for a one-year grace period, to no avail.

The group protesting Tuesday delivered the letter to the offices of Arkansas’ two U.S. Senators, John Boozman and Tom Cotton, in the Victory Building and then to Gov. Sarah Huckabee Sanders’ office in the Capitol.

Sanders’ and Boozman’s staff accepted the letter; no one answered the door at Cotton’s office.

Jennifer Cole said she believed Boozman’s staff listened to her and the other protesters.

“I don’t know that we’re going to get the senator’s ear, but we can hope,” she said.

Cole said she lost access to the Supplemental Nutrition Assistance Program, commonly known as food stamps, for six months due to paperwork issues at DHS.

“I called them and they had received [my paperwork], but nobody had had a chance to look at it, and that falls back on us,” she said.

Children have made up more than 40% of Arkansas Medicaid enrollees since July 1, according to DHS data.

Nearly 40% of the state’s disenrolled Medicaid clients in April and May were children, according to data collected by health policy researcher KFF, which has been tracking the Medicaid unwinding process nationwide.

Sholanda Woods said her daughter is one of them.

“[Sanders] came into office talking about how she loves our babies and our kids and stuff,” said Woods, a single parent. “…My child has diabetes and I can’t go to the pharmacy and get her medicine or anything like that.”

Spokespeople for Boozman and Cotton did not respond when asked via email whether the officials had seen the protesters’ letter as of Tuesday afternoon.

Alexa Henning, a spokeswoman for Sanders, said in an email that Arkansas has been following state and federal law throughout the unwinding process.

“DHS is using every tool to ensure people who are eligible remain covered and working with those who are no longer eligible to get coverage through their job or the healthcare marketplace,” Henning said.