Tag: Fraud

[MM Curator Summary]: An Iowa referral agency double-billed the state for services over a 4 year period.

 
 

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

A special investigation by the state auditor’s office has found a non-profit in western Iowa was double-billing for some services.

Iowa Department of Public Health officials asked for the review of a non-profit called FAMILY, Inc. It links needy residents to a variety of government services for women, children and families in Pottawattamie and Mills Counties. The review centered on the organizations’s contracts with state agencies — one for home visits with pregnant women and families with young children and the other for a program called Early Childhood Iowa.

Auditors determined that over a four-year period, FAMILY, Inc. billed Medicaid for more than 20-thousand dollars in services already covered by the contracts. State Auditor Rob Sand said in the report that due to a lack of records, it was not possible to determine if improper billing happened before July 1, 2017. According to the auditor, the Iowa Department of Public Health adopted more cross-checks last year to ensure other providers aren’t double-billing for these same services.

A spokesperson for FAMILY, Inc. was not immediately available for comment when the special investigation by the state auditor’s office was released this morning.

 
 

Clipped from: https://www.radioiowa.com/2022/05/10/report-finds-western-iowa-agency-improperly-billed-medicaid-for-some-services/

[MM Curator Summary]: A substance abuse provider is suing its software vendor, claiming the software vendor is at fault for $1M in overbillings to the state.

 
 

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.

 
 

 
 

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Patrick Lakamp

An $18.16 mistake – made over and over again – has put the Community Action Organization of Western New York in a half-million dollar bind.

The organization mistakenly added a weekly charge of $18.16 when billing Medicaid for many of those in its outpatient chemical dependence services program, according to an audit by the New York State Office of Medicaid Inspector General.

Extrapolating the mistaken charge for all 271,809 claims during a three-year audit period, the audit estimated the CAO overcharged the government potentially as much as $992,268.

The office said the CAO could settle the matter by paying back $491,508. But the nonprofit, which spends millions of state and federal dollars fighting poverty, spent the improper reimbursements and does not have the money to repay the amount, according to a lawsuit it recently filed in State Supreme Court.

The CAO blamed the overbilling on its software vendor, TenEleven Group Inc. of Amherst. The lawsuit alleges the vendor “lulled CAO staff into complacency by making false and misleading representations.”

The lawsuit seeks “not less than $1 million” from TenEleven Group. 

“The complaint speaks for itself,” said attorney James J. Zawodzinski Jr., who represents the CAO. “Because the matter is in litigation, we are limited in the comments we can make.”

The lawsuit relates to billings and services provided by TenEleven Group from 2014 to 2016.

“Audit findings are common, and these findings are a relatively small percentage of the agency’s overall billings,” Zawodzinski said. “The litigation seeks to recover the resulting audit finding from the software vendor who the complaint alleges made errors which caused the bulk of the audit finding.”

TenEleven Group said it’s not responsible for the mistaken billing.

“CAO’s lawsuit is nothing more than a deflection tactic, seeking to cast blame on a third party for CAO’s own failure to ensure it followed proper billing practices and appropriately handled public funds,” the company said in a statement. “TenEleven merely provided software to CAO, and is not, nor was it ever responsible for CAO’s billing, processing, accounting, or reporting practices to state and federal agencies. We believe the lawsuit is meritless and intend to vigorously defend against the allegations in the complaint.”

It is not clear from the CAO’s lawsuit whether any overbilling occurred after the audit period, and if so, how much. If the improper $18.16 charges continued after the audit period, the organization has the ability to report overpayments through the inspector general’s self-disclosure program.

Thomas Kim, president and CEO of the CAO, did not return messages seeking more information about the overcharges.

“To date, TenEleven Group has not responded to, in any meaningful fashion, CAO’s attempts to resolve the present dispute,” according to the CAO’s March 22 lawsuit.

The Office of Medicaid Inspector General audited a random sample of claims from January 2014 through December 2016 submitted by the CAO’s Drug Abuse and Treatment Program. In all, the program submitted 271,809 claims totaling $7.9 million during the period.

 
 

Audit of CAO opioid treatment program

New York State’s Medicaid inspector general audited a random sample of Medicaid claims submitted the the CAO of Western New York’s Drug Abuse …

Most of those receiving services in the program are enrolled in Medicaid, the federal-state health care insurance program that helps pay for health care for low-income people of any age.

When the DART clinic provides services to those on Medicaid, it bills Medicaid for reimbursement.

For years before the audit, TenEleven Group provided software to CAO under an agreement that both sides modified from time to time. In May 2014, TenEleven Group and CAO amended it to put in place “an enhanced suite” of software and services, according to the lawsuit. The software included an upgraded billing component enabling reimbursement claims to be submitted electronically.

In its lawsuit, the CAO said it paid “substantial sums” for the software package, including licensing fees and ongoing maintenance costs.

The CAO, according to the lawsuit, relied on, and continues to rely on, TenEleven Group’s software to manage billings, primarily for the Medicaid program. CAO employees continue to input weekly billings for services provided to DART clinic patients into the TenEleven Group billing and financial module. TenEleven Group’s software transmits the nonprofit’s claims to the electronic Medicaid New York claims system portal in CAO’s name for payment directly to CAO, according to the lawsuit.

Staff at the DART clinic became aware the software had “a significant defect” after using the upgraded software for a period of time, according to the lawsuit. After learning of the $18.16 additional weekly charge, the staff alerted TenEleven Group, according to the lawsuit. Either an error in the software or in the billing submissions protocol appeared to trigger additional payments from Medicaid for which the CAO had not submitted claims for reimbursement.

TenEleven Group investigated the source of the overcharges and offered assurances the DART staff was correctly inputting claims information, according to the lawsuit.

TenEleven Group told the CAO that it had identified the cause of the defect and addressed it with Medicaid and “repeatedly assured” the CAO that the billing software “was functioning properly” and transmitting accurate information to the eMedNY claims system, according to the lawsuit.

The CAO renegotiated its agreement with TenEleven in 2018, paying higher services fees to continue using the software.

The CAO’s lawsuit alleges TenEleven Group “fraudulently induced CAO to continue as a customer … despite knowing that they had not mitigated the defect CAO previously brought to their attention.”

“TenEleven failed to disclose what is now apparent: that whatever actions TenEleven, through its representatives, may have been taking, those actions were not effective either to rectify the software defect or to reduce CAO’s now-expanding liability to the Medicaid program,” according to the lawsuit.

The CAO received $36.9 million in government grants, according to a 2019 tax filing.

The CAO in 2018 served 642 people in its outpatient opiate treatment clinic, according to the tax filing. The DART clinic conducted 177,252 dispensing visits and 14,883 “clinical episodes of care” that year, and it reported that 78% of those in the program established and maintained abstinence from drug and alcohol use.

 
 

 
 

 
 

Clipped from: https://buffalonews.com/news/local/cao-overbilled-medicaid-18-16-at-a-time-files-1m-lawsuit-for-being-lulled-into/article_7b831d6e-bfef-11ec-9cdf-5b3a7455ded0.html

 
 

[MM Curator Summary]: Springbok Health will pay up to $335k for upcoding simple services to get paid as if they were complex medical services.

 
 

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

A substance abuse treatment clinic in Pueblo West has agreed to pay at least $125,000 to resolve allegations by the Colorado U.S. Attorney’s Office that it violated the False Claims Act by billing Medicare and Medicaid for complex medical services that were never rendered.

Springbok Health Inc., a clinic with locations in Colorado Springs and Pueblo West, and its owner and CEO Mark Jankelow, agreed to pay at least $125,000 and as much as $335,494 in the settlement, the Colorado U.S. Attorney’s Office said in a statement.

The claims settled by the agreement are allegations only, according to the U.S. Attorney’s Office, and do not reflect a determination of liability. The resolution is based on Springbok’s and Jankelow’s ability to pay.

From 2017 to 2019, Springbok allegedly billed Medicare and Medicaid for “expensive medical evaluation and management services when, at most, less expensive counseling services were provided,” the statement said.

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“Billing Medicare and Medicaid for more expensive services than were actually rendered depletes the limited resources of these vital health care programs,” Principal Deputy Assistant Attorney General Brian M. Boynton said in the statement. “We will continue to safeguard taxpayer dollars and hold accountable those who knowingly misuse such funds.”  

“Providing substance abuse treatment is a vital tool in combating the opioid epidemic devastating Colorado communities,” said U.S. Attorney Cole Finegan for the District of Colorado. “But offering treatment to addicts does not excuse fraud. Our office will continue to pursue claims against providers whose fraudulent billing practices take valuable resources away from victims of the opioid crisis.”

The False Claims Act, which Springbok and Jankelow were accused of violating, is a federal law that imposes liability on companies and individuals who defraud governmental programs. It dictates that violators are liable for treble damages — damages up to three times actual or compensatory damages awarded to a prevailing plaintiff — plus a penalty that is linked to inflation. 

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In addition to allowing the U.S. government to pursue perpetrators of fraud, the FCA allows private citizens to file suits on behalf of the government in “qui tam” suits against those who have defrauded the government. 

Private citizens who successfully bring qui tam actions may receive a portion of the government’s recovery.

The civil settlement with Springbok includes the resolution of an action brought under the qui tam or whistleblower provisions.

The citizen who brought the action, identified in the U.S. Attorney’s Office statement only as “Ms. Chaudhry,” will receive at least $22,500, and up to $60,389 as her share of the settlement.

Springbok and Jankelow could not be reached for comment by The Chieftain’s press deadline Tuesday.

Chieftain reporter Zach Hillstrom can be reached at zhillstrom@gannett.com or on Twitter @ZachHillstrom 

 
 

Clipped from: https://www.chieftain.com/story/money/2022/04/19/pueblo-west-springbok-health-clinic-settles-medicare-medicaid-fraud-claims/7368884001/

[MM Curator Summary]: Two LA mental health providers stole $3.5M from Medicaid by paying members to enroll in their program and submitting false claims for services.

 
 

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.

 
 

Tuesday, two northwest Louisiana healthcare providers were sentenced in connection to healthcare and wire fraud. 

Marty T. Johnson, 59, and Keesha Dinkins, 45,  were sentenced on April 19, after pleading guilty to defrauding the Medicaid Program of $3.5 million. 

Johnson of Shreveport, was sentenced to 60 months in prison, followed by 1 year of supervised release. Dinkins of Bossier City, was sentenced to 24 months in prison, followed by 1 year of supervised release.

In addition, Johnson and Dinkins were ordered to jointly pay restitution in the amount of $3.5 million.

According to information presented to the court, Johnson owned and operated Positive Change Counseling Agency (Positive Change) located in Shreveport from Jan. 2013 to Jan. 2018. Keesha Dinkins was a manager and supervisor at Positive Change.

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Positive Change provided mental health rehabilitation and related services to Medicaid beneficiaries in the Caddo and Bossier Parish areas.

From 2014 to Jan. 2018, Johnson submitted fraudulent claims for mental health rehabilitation and non-emergency transportation services on behalf of Positive Change.

Dinkins knew that Johnson submitted these fraudulent claims which were not performed or rendered. These fraudulent claims resulted in Positive Change receiving payments from Medicaid to which it was not entitled.

Johnson admitted to paying individuals money to enroll with Positive Change, increasing the capacity for Positive Change to bill Medicaid for services that were not rendered.

Johnson instructed employees, and Dinkins supervised those employees, at Positive Change to create false client files to conceal from Medicaid and insurance company auditors and inspectors that it had not performed the services related to its previously submitted claims which had already been reimbursed by Medicaid.

In order to create these false client files, sections from different client documents were physically cut to create inserts that were glued into blank client log templates. These templates with the glued inserts were then photocopied to create the appearance of legitimate documents.

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Johnson and Dinkins supervised and knowingly and willfully instructed the employees that were creating these false client files to place the false and fictitious photocopied, cut and pasted, documents into the client files.

The case was investigated by the U.S. Department of Health and Human Services– Office of Inspector General, Louisiana State Attorney General’s Office-Medicaid Fraud Control Unit and Federal Bureau of Investigation. 

Makenzie Boucher is a reporter with the Shreveport Times. Contact her at mboucher@gannett.com.

 
 

Clipped from: https://www.shreveporttimes.com/story/news/local/2022/04/19/shreveport-area-mental-health-workers-sentenced-medicaid-fraud-case/7370079001/

[MM Curator Summary]: Th NY Comptroller continues to find extensive improper Medicaid payments in the Medicaid program year after year.

 
 

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.

 
 

New York’s Medicaid program incorrectly paid out nearly $1 billion to providers over a four year period, according to two audits released Tuesday by state Comptroller Tom DiNapoli’s office. 

The audits found the improper payments were made for services that included ordering, prescribing, referring and attending providers who are no longer enrolled in the Medicaid program at the time of the service. 

At the same time, improper payments of $5.8 million were used for services for providers who were excluded from participating in the Medicaid program due to previous improper behavior or wrongdoing. Changes to the program known as eMedNY were made in February 2018 that had led to a notable drop in the number of improper payments, the audit found. 

Nevertheless, from March 2018 to December 2019, the comptroller’s office still found $45.6 million in payments for more than 135,000 services to providers who are not eligible. 

“Medicaid is a critically important program, but its payment system is rife with errors,” DiNapoli said. “My auditors found the system was allowing payments on claims involving providers who were not certified to treat Medicaid patients. This not only costs taxpayers, but also allows providers who should be excluded, and may be unqualified, to treat patients. DOH must improve its efforts to fix the shortcomings with its billing system.”

The comptroller’s office recommended the state Department of Health review payments for Medicaid claims involving inactive providers, strengthen controls to prevent improper payments and update guidelines to clarifying billing rules. 

 
 

Clipped from: https://spectrumlocalnews.com/nys/central-ny/ny-state-of-politics/2022/04/19/comptroller-audit-finds-nearly–1b-in-medicaid-billing-errors

[MM Curator Summary]: BayCare and several other Florida hospitals are paying up in a whistleblower suit that shows them gaming the Medicaid provider tax game.

 
 

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.

 
 

 
 

BayCare has agreed to pay a $20 million settlement to the federal government to resolve allegations that it violated federal law to boost its share of Medicaid funding.

The Tampa Bay hospital chain made donations to the Juvenile Welfare Board of Pinellas County from October 2013 to September 2015. That was funneled to the state Agency for Healthcare Administration for Florida’s Medicaid program, according to the U.S. Department of Justice. The bulk of those funds were then paid back to BayCare for treating patients covered by Medicaid.

Since the funds were classified as donations, the federal government was required to make matching payments — which also went to BayCare.

The company was thus able to recoup the bulk of its original donations and receive the matching federal funds, according to the settlement agreement. That violates federal law, which views requests for matches based on donations from medical providers as false claims.

The federal complaint does not say who arranged, directed or approved the scheme.

Medicaid covers medical costs for some low-income households and individuals with disabilities. It is jointly funded by the federal government and the states.

“When health care providers participate in fraud schemes to boost federal payments, they do so at the expense of federal health care programs,” said a statement from
Special Agent in Charge Omar Pérez Aybar of the U.S. Department of Health and Human Services Office of Inspector General. “Our office is committed to protecting the integrity of the Medicaid Program, and we will use all available civil remedies to recover the ill-gotten gains obtained by those who defraud it and other government health care programs.”

Federal officials said the four BayCare hospitals involved are all in Pinellas County: St. Anthony’s Hospital in St. Petersburg, Mease Countryside Hospital in Safety Harbor, Mease Dunedin Hospital and Morton Plant Hospital in Clearwater.

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BayCare, which is headquartered in Clearwater, runs 15 hospitals in the Tampa Bay region. In a statement to the Tampa Bay Times, the company described the settlement as a “disagreement with the government over a complex regulatory question.”

“BayCare has admitted no wrongdoing and expressly denies the allegations against it, but we have settled to avoid the delay, uncertainty, and expense of litigation. At all times, BayCare fully cooperated with the government with respect to this matter. BayCare remains committed to the highest integrity practices, and we look forward to continuing to serve all patients and our communities’ health needs.”

The Justice Department said it received information about the donations from a former hospital reimbursement manager in Florida who, under the terms of the whistleblower provisions of federal law, will receive $5 million from the settlement. The settlement agreement also requires BayCare to pay $25,000 to the whistleblower for expenses and legal costs.

“We will use all available civil remedies to recover the ill-gotten gains obtained by those who defraud it and other government health care programs,” said a statement from
U.S. Attorney Roger Handberg of the Middle District of Florida.

A complaint filed in federal court on behalf of the whistleblower states that other Pinellas hospitals and a clinic also used donations and reimbursements to boost their Medicaid payments over a 4-year period starting in 2012. The Juvenile Welfare Board agreed to accept the “impermissible” donations and, in return, was allowed to keep 10 percent of the funds.

Between 2011 and 2015, the scheme resulted in $52 million in additional Medicaid payments, the complaint states. The juvenile welfare board’s share of donations involving all the hospitals named in the complaint was $3.7 million over four years.

Juvenile Welfare Board spokesperson April Putzulu said the donations predate the tenure of CEO Beth Houghton, who was hired in 2019. Putzulu said the publicly-funded agency will not comment on litigation involving another entity.

The other local hospitals named in the whistleblower complaint are Johns Hopkins All Children’s Hospital and Bayfront Health St. Petersburg hospital.

Officials from Community Health Systems, a Fortune 500 company in Tennessee that owned Bayfront when the donations were made, did not respond to a call or emails seeking comment Thursday.

Bayfront Health St. Petersburg was purchased by Orlando Health in 2020. The company released this statement:

“Under Orlando Health’s leadership, Bayfront Health St. Petersburg adheres to strict internal compliance and ethics standards and oversight which would prevent this kind of unfortunate event.”

Johns Hopkins All Children’s Hospital in St. Petersburg. [ DIRK SHADD | Times ]

Officials from Johns Hopkins All Children’s Hospital said in a statement that the hospital is focused on providing the best possible care for children: “We are still in litigation related to this matter and limited in our ability to provide further statements.”

Also named in the whistleblower complaint is Community Health Centers of Pinellas, which operates at 13 clinics around the county and is now named Evara Health. A call requesting comment was not returned.

The status of the federal cases involving Bayfront Health St. Petersburg and Evara Health were not known.

Clipped from: https://www.tampabay.com/news/health/2022/04/07/baycare-pays-20-million-for-improperly-boosting-medicaid-payments/

[MM Curator Summary]: Jennifer McGevna was arrested for submitting false claims for mental health services in CT.

 
 

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

A Colebrook woman has been charged with fraudulently billing the government’s Medicaid health insurance program, according to state authorities.

Jennifer Lefebre-McGevna, 45, of Flagg Hill Road, Colebrook, was arrested Thursday by inspectors from the Medicaid Fraud Control Unit in the Office of the Chief State’s Attorney, and charged with one count each of first-degree larceny by defrauding a public community and health insurance fraud, state authorities. said in a statement.

Between 2017 and 2020, Lefebre-McGevna, a behavioral health clinician, allegedly billed the Connecticut Medicaid Program for “psychotherapy services that were not provided and billed for services rendered by unlicensed individuals,” the statement said, citing an arrest warrant affidavit. “By submitting these bills, Lefebre-McGevna stole $148,102.80 from the Medicaid program.”

Further, the submission of claims to the Department of Social Services “provided by Lefebre-McGevna contained false, incomplete, deceptive or misleading information which constitutes the crime of Health Insurance Fraud,” the statement said.

Lefebre-McGevna was free on a $150,000 non-surety bond, and is scheduled to appear in Harford Superior Court on April 13.

The case will be prosecuted by the Medicaid Fraud Control Unit, the statement said.

The unit noted it “is grateful for the assistance it received in the investigation from the State Department of Social Services Office of Quality Assurance, and the Rocky Hill Police Department.”

Anyone with knowledge of suspected fraud or abuse in the public health care system is asked to contact the Medicaid Fraud Control Unit at the Chief State’s Attorney’s Office at 860-258-5986.

 
 

 
 

Clipped from: https://www.courant.com/breaking-news/hc-br-colebrook-woman-arrested-fraud-20220405-73f7xuytsvfgbhncpcobulpzne-story.html

[MM Curator Summary]: Pamela Bell falsified claims to make it look like her mental health company was using licensed therapists.

 
 

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

 
 

 
 

LITTLE ROCK, Ark. (KAIT) – A White County woman faces two counts of Medicaid fraud after authorities said she turned in over 300 fraudulent claims to the system over a three-year period.

Pamela Townsend-Bell of Judsonia was arrested earlier this month after an investigation by the Arkansas Attorney General’s office.

A statement posted Tuesday said the allegations centered around Townsend-Bell fraudulently billing Medicaid while owning the mental health agency, “I’m a 10 Wellness Center, LLC”, in Searcy.

“Townsend-Bell billed Medicaid for one-on-one individual counseling services provided by unlicensed staff, listing herself as the performing provider,” Attorney General Leslie Rutledge said. “The unlicensed staff included non-paid interns and office staff. Medicaid requires these types of outpatient mental health services to be provided by licensed therapists.”

The fraudulent claims made by Townsend-Bell were about $18,600, according to Rutledge.

She added Townsend-Bell purposely made false statements for payments that violated state Medicaid rules, plus made false entries in medical records “indicating she provided services to Medicaid recipients.”

Townsend-Bell appeared in Pulaski County District Court on March 18 and was released, pending further proceedings on the issue, Rutledge said.

 
 

Clipped from: https://www.kait8.com/2022/03/31/woman-charged-with-medicaid-fraud/