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Las Vegas woman sentenced in Medicaid fraud case

[MM Curator Summary]: Jessica Brown and Shonna Marshall have been convicted of using a ghost company to steal NV Medicaid dollars.

 
 

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.

 
 

 
 

LAS VEGAS (KLAS) — A Las Vegas woman has been sentenced to prison for submitting false claims in a Medicaid fraud case.

On Tuesday, a judge sentenced Jessica Celeste Brown, 33, of Las Vegas to 18 – 48 months in prison.

The fraud case also names Brown as failing to maintain adequate records to substantiate claims submitted to Nevada Medicaid. The incidents occurred between October 2017 to February 2018.

The investigation revealed that Brown and her co-defendant, Shonna Nicole Marshall created a ghost company for the sole purpose of fleecing as much money as possible as quickly as possible.

In February, Marshall was sentenced in another case for committing 27 felony counts of Medicaid fraud and money laundering using a similar scheme where she formed a ghost company solely to fraudulently bill Medicaid.

Marshall is currently imprisoned for her repeated efforts to defraud Nevada Medicaid.  

Along with the prison sentence, Brown is also being placed on probation and is ordered to pay more than $150,000 in restitution, penalties, and costs. She is also prohibited from employment with any Medicaid-contracted companies.

 
 

Clipped from: https://www.8newsnow.com/news/local-news/las-vegas-woman-sentenced-in-medicaid-fraud-case-2/

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Compassionate Homecare to Pay $6.53M to Resolve Allegations; OIG Releases Medicaid Fraud Report

[MM Curator Summary]: Compassionate Homecare execs stole $6.5M from MA Medicaid with an un-authorized services scam.

 
 

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.

 
 

Compassionate Homecare Inc., has agreed to pay $6.53 million to MassHealth in order to resolve allegations of unauthorized billing for services.

The settlement irons out a 2018 lawsuit filed by the Attorney General’s office against Compassionate. The state’s lawsuit alleges that the company stole millions of dollars from MassHealth.

Aside from the $6.53 million settlement, $375,000 will be earmarked for payment of unpaid wages for former Compassionate employees.

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“This settlement is a victory for MassHealth and for workers who deserve to be paid back for missed wages,” Maura Healey, the attorney general of Massachusetts, said in a press release. “We will continue to protect the integrity of our MassHealth program and ensure compliance with our wage and hour laws.”

Compassionate owner, Francis Kimaru, pleaded guilty to separate criminal charges brought in by the Attorney General’s Medicaid Fraud Division in September 2019. Kimaru confessed to over-billing and falsely billing for services that were not authorized by a physician, or provided to patients.

The company also filed for bankruptcy in May 2020.

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OIG releases Medicaid fraud report

In addition to Massachusetts’ fraud news, the U.S. Department of Health and Human Services Office of Inspector General (OIG) recently released its latest Medicaid fraud report.

The report examines data from 2021 annual statistical reports that 53 Medicaid Fraud Control Units (MFCU) submitted to the OIG.

Overall, fraud convictions were about 70% of all 2021 convictions.

OIG saw an increase in total convictions resulting from MFCU cases, which went from 1,017 in 2020 to 1,105 in 2021. MFCU cases checked in at 780 convictions for fraud and 325 convictions for patient abuse or neglect.

Personal care workers and agencies had the highest number of fraud convictions each year from 2017 through 2021 compared to other types of providers.

In fact, there were 329 fraud convictions involving personal care workers and agencies, or 42% of the total 780 fraud convictions in 2021.

Personal care workers, or other home care aides, also made up a significant amount of the convictions for patient abuse or neglect. Specifically, workers in this sector accounted for 69, or 21%, of the total 325 convictions for patient abuse or neglect.

In total, MFCU criminal recoveries increased from $173 million in 2020 to $857 million in 2021. OIG credits cases prosecuted by MFCUs in Virginia and Texas for the increase in criminal recovery amounts.

In 2021, the OIG saw the total number of civil settlements and judgments decrease from 786 in 2020 to 716, though the pandemic may have resulted in skewed numbers.

 
 

Clipped from: https://homehealthcarenews.com/2022/03/compassionate-homecare-to-pay-6-53m-to-resolve-allegations-oig-releases-medicaid-fraud-report/

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Medicaid fraud bill introduced

[MM Curator Summary]: A proposed federal law would expand efforts to ensure Medicaid benefits do not go to those eligible for them.

 
 

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.

 
 

WASHINGTON Sen. John Kennedy (R-La.)  joined Sen. Jim Inhofe (R-Okla.) in introducing the Protecting Medicaid Beneficiaries Act to expand existing safeguards for Medicaid.

 “The Protecting Medicaid Beneficiaries Act would safeguard tax dollars by helping ensure Medicaid assistance goes to those who actually need it, and I’m proud to partner with Sen. Inhofe to protect Medicaid recipients,” said Kennedy.

 “If you look at the numbers, it is clear that fraud is rampant within Medicaid, and billions of dollars are wasted every year as a result. Those who truly need Medicaid, should be able to get Medicaid, and our taxpayer dollars should be preserved to that end. For that to happen, we must ensure that individuals trying to game the system are discovered in the first place. That’s why I am glad to introduce the Protecting Medicaid Beneficiaries Act—a bill that will go a long way in ensuring those who need Medicaid, get Medicaid by rooting out misuse of taxpayer dollars within the system and promoting fiscal integrity,” said Inhofe.

 The Protecting Medicaid Beneficiaries Act would expand the Asset Verification Services (AVS) program, which helps ensure that Medicaid beneficiaries are legally eligible to receive benefits, to all Medicaid applicants.  According to certain estimates as of 2012, waste and fraud accounted for the loss of 10 percent of Medicaid and Medicare spending.  As of 2018, the Louisiana Department of Health had sent Medicaid payments to many individuals who were ineligible for them, including people making more than $100,000 annually.

 
 

Clipped from: https://www.thewestsidejournal.com/news/medicaid-fraud-bill-introduced/article_5d1bfae8-b041-11ec-9da5-bf925fb09636.html

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Jury acquits men of all counts in Medicaid fraud case

MM Curator summary

[MM Curator Summary]: A WY behavioral health provider team has been acquitted, but the damage to their business has been done.

 
 

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.

 
 

 
 

POWELL — Over the span of eight days in a Cheyenne courtroom, federal prosecutors laid out a case that had been a decade in the making, arguing that a Powell treatment center had defrauded Medicaid out of millions of dollars.

After 5 1/2 hours of deliberations, however, a jury rejected the allegations.

The 12-member panel voted unanimously on Thursday to acquit former Northwest Wyoming Treatment Center employees Matthew “Ty” Barrus, Greg Bennett and Devin Dutson, finding them not guilty of all charges brought by the U.S. Attorney’s Office. The men didn’t present a formal defense, as their attorneys felt it wasn’t necessary, but sought to show that Northwest Wyoming Treatment Center provided good care and believed it was in compliance with Medicaid rules.

Barrus, who served as the center’s executive director, said the verdicts brought relief that a 6 1/2- year “nightmare” might have come to an end. He said he was also thankful for the ability to defend himself within a fair judicial system, his defense attorneys and the support of his family and friends, among other things. But Barrus said it was not a victory.

For one thing, he noted that Northwest Wyoming Treatment Center — which was shut down and had all of its assets seized by the federal government years ago — no longer exists.

“We really liked our program and felt that we were successful,” he said, “And it’s been tough.”

Until state and federal investigators came knocking on the center’s door in December 2015, Barrus said they “never thought that we were even close to doing anything wrong.”

Northwest Wyoming Treatment Center provided substance abuse treatment from 2009 to 2016, serving youth between the ages of 12 and 17 who were struggling with addictions to controlled substances.

At its peak, the center had roughly 20 employees, with Barrus as executive director, Bennett as clinical director and Dutson as a therapist.

Most of the center’s clients came from court-ordered placements — many from the Wind River Indian Reservation — and spent months in the program. They were, according to the defendants’ attorneys, “some of the most psychologically damaged, and hard to reach, children in the State of Wyoming.”

Barrus said the clients were addicts dealing with mental issues, trauma, abuse, generational addiction, homelessness and/or risky behavior, and they were there to receive 24/7 residential treatment.

“It was hard work dealing with some of the kids,” he said, noting the circumstances they came from.

But Barrus also called it a privilege, saying they were generally good kids dealing with addictions.

When the Commission on Accreditation of Rehabilitation Facilities surveyed the center in December 2015, it noted “strengths in many areas” and re-certified the facility for the three-year maximum.

“The staff at NWTC provides the consistent caring and nurturing that has often been missing in the lives of the clients served,” surveyor David Blondeau wrote in part, adding that the staff were “highly credentialed and utilize state-of-the-art interventions.”

However, roughly a week later, a team of investigators from the Wyoming Department of Health’s Medicaid Program Integrity and law enforcement officers came to the center’s door, as part of an investigation of the organization’s billing practices.

Most of the clients at the nonprofit center were Wyoming Medicaid beneficiaries. Over a period of six years, NWTC billed Medicaid more than $8.5 million for the careit provided to more than 100 clientsand authorities came to believe that much of the billing was excessive and inappropriate, including when compared to other facilities.

In January 2016, Program Integrity demanded that the center repay nearly $1.35 million, which effectively shut the operation down.

Then in March 2019, the U.S. Attorney’s Office moved to seize all of the center’s property — including three buildings, a vacant lot and cash — asserting that the assets represented the proceeds of false and fraudulent bills submitted to Medicaid; the center’s board agreed to forfeit the property. Then in September 2019, federal prosecutors indicted Barrus, Bennett and Dutson on a combined total of 14 felony charges.

A grand jury generally alleged that the men had submitted claims for activities that didn’t qualify as therapeutically necessary substance abuse treatment, for activities not covered by Medicaid and for services the center or their staffers weren’t authorized or licensed to provide.

The indictment also alleged the center had “up-coded” some claims — for instance, by billing what the government saw as group recreational activities at the higher rate for individual treatment. A federal prosecutor asserted earlier this year that NWTC had billed “all day every day for activities that are not covered by Medicaid (including sleeping, eating, playing video games, weightlifting and traveling the state for recreational activities) as if those activities were covered substance abuse treatment.”

 
 

Clipped from: https://www.thesheridanpress.com/news/regional-news/jury-acquits-men-of-all-counts-in-medicaid-fraud-case/article_6b5677c4-a488-11ec-932d-5f3d36b8b1ab.html

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Mallinckrodt inks $260M settlement with US to resolve Medicaid underpayment and kickbacks allegations

 
 

MM Curator summary

[MM Curator Summary]: The drug company depressed rebates it should have paid to Medicaid and set up a foundation to cover member copays when it shouldn’t have.

 
 

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 month after a U.S. bankruptcy court signed off on Mallinckrodt’s reorganization plan, the company has agreed to a $260 million settlement to resolve claims by the Department of Justice surrounding its management of its controversial Acthar Gel drug.

The U.S. said that Mallinckrodt underpaid Medicaid rebates and used a foundation to pay illegal copay subsidies, violating an anti-kickback statute by inducing patients to use the treatment.

The settlement resolves separate cases brought by the government following whistleblower complaints in 2019 and 2020, both involving the popular drug used to curb seizures in children.

The settlement was hastened by the recent decision on Mallinckrodt’s financial condition, which was determined in bankruptcy court in Delaware.

“Mallinckrodt illegally reduced the amounts it paid to state Medicaid programs by improperly calculating the rebates it owed,” U.S. attorney Rachael Rollins said in a statement. “The company unlawfully siphoned money out of the Medicaid program which poor people depend on for their medical care.”

The company resolved (PDF) the Medicaid rebates claim for $234.7 million and took (PDF) care of the kickback claim for $26.3 million. Progressive payments will be spread over seven years.  

“We disagree categorically with the government’s characterizations, but are pleased to have these matters behind the company and note that the settlements contain no admissions of wrongdoing,” a Mallinckrodt said in an emailed statement.

Late last month, the bankruptcy court signed off on a $65.75 million settlement between Mallinckrodt and investors who claimed that the company concealed its reliance for federal reimbursements for Acthar Gel.

In 2020, the drug drew scrutiny from Congress after its price skyrocketed over the last two decades—from $50 per vial to $40,000. Mallinckrodt picked Acthar Gel up in 2014 when it paid $5.8 billion to acquire the drug’s original developer, Questcor Pharmaceuticals.

The Medicaid rebate claims against Mallinckrodt spanned from 2013 to 2020, when the company allegedly underpaid rebates based on its claim that Acthar Gel was a new drug in 2013 when it actually entered the market decades earlier.

The kickback claims spanned from 2010 to 2014, when Questcor was alleged to have partnered with the Chronic Disease Fund to subsidize Medicare copayments to market the drug as “free” while increasing its price.

As part of the settlement, Mallinckrodt will enter a five-year corporate integrity agreement (CIA) that contains unique drug price transparency and monitoring provisions focused on Medicaid and patent assistance program activities.

Mallinckrodt entered bankruptcy because of its mounting liabilities over its alleged role in contributing to the opioid crisis. It agreed to a $1.6 billion settlement to resolve those claims.

 
 

Clipped from: https://www.fiercepharma.com/pharma/mallinckrodt-agrees-260-million-settlement-us-over-medicaid-underpayment-and-kickback

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Officials: Lab pays $4.8 million for overcharging CT Medicaid patients

MM Curator summary

[MM Curator Summary]: The lab was charging CT Medicaid4x what it was charging other payers for urine drug tests, and that’s a no-no.

 
 

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 national laboratory paid nearly $4.8 million to resolve allegations it overcharged the Connecticut Medicaid program for certain lab services over the span of several years, according to officials on Monday.

Connecticut Attorney General William Tong and other officials announced the settlement with Redwood Toxicology Laboratory on Monday, alleging that the lab violated the state’s “Most Favored Nation” regulation.

The regulation indicates that clinical labs should not seek payment from Connecticut Medicaid for services at a price higher than the lowest price the lab charges for the same or similar services from other third parties.

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The lab, based in Santa Rosa, Calif., offers lab testing services like urine drug testing services for substance abuse patients in the Connecticut Medicaid program.

Specifically, officials said, the lab regularly accepted payments from Connecticut Medicaid for specific urine drug tests at a rate of $38 per test. However, the lab was charging other third parties from $2 to $10.50 for the same or similar tests, officials said.

The lab agreed to pay $4,797,578 to cover claims submitted to the Connecticut Medicaid program from Jan. 1, 2015, through Feb. 24, 2018.

Anyone who suspects health care fraud is encouraged to report it by calling 1-800-HHS-TIPS.

 
 

Clipped from: https://www.ncadvertiser.com/news/article/Officials-Lab-pays-4-8-million-for-overcharging-16983837.php

 
 

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Overbilling Medicaid is also aggravated identity theft, says full 5th Circ

 
 

MM Curator summary

[MM Curator Summary]: A recent ruling may bring a harsher treatment of Medicaid fraud, including a mandatory addition of 2 years to sentencing.

 
 

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.

 
 

 
 

 
 

REUTERS/Jonathan Bachman

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  • Summary
  • Law firms

 
 

  • En banc court divides 10-8, with five separate opinions
  • Dissents point to circuit split, SCOTUS warning against ‘breathtaking’ scope

The company and law firm names shown above are generated automatically based on the text of the article. We are improving this feature as we continue to test and develop in beta. We welcome feedback, which you can provide using the feedback tab on the right of the page.

(Reuters) – A federal appeals court on Wednesday affirmed that overbilling Medicaid for services to a patient is not just healthcare fraud, but “aggravated identity theft” under a separate statute that includes a mandatory two-year sentence enhancement.

The full 5th U.S. Circuit Court of Appeals divided 10-8 on the question of whether David Dubin, who managed billing for his father’s psychology practice in Texas, violated the identity-theft law by falsifying the date and scope of services provided to “Patient L” – a real patient who had authorized him to bill Medicaid for the services provided.

A three-judge panel had affirmed Dubin’s convictions, one-year sentence for Medicaid fraud, and two-year sentence for identity theft related to Medicaid fraud in 2020. However, one judge pointed to a split in the federal circuits that led the 5th Circuit to grant en banc review last year.

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Dubin’s lawyers at Gross & Esparza and O’Melveny & Myers argued that the enhancement statute must require misrepresentation of the patient’s identity, not just misrepresentation of services, or the “enhancement” would increase the sentence for every case of Medicaid fraud. They drew amicus support from the National Association of Criminal Defense Lawyers.

The eight dissenters agreed, with separate opinions by Circuit Judge Janet Elrod and Gregg Costa highlighting 1st, 6th, 7th, 9th, and 11th Circuit decisions that support Dubin’s arguments. Costa also noted that the U.S. Supreme Court has repeatedly cautioned appellate courts not to interpret federal criminal statutes in a “breathtakingly” broad manner.

However, Chief Circuit Judge Priscilla Owen and eight other judges rejected that argument in a one-page per curiam decision. In a separate concurrence, Owen noted that the statute enhances the penalty for specified offenses, including Medicaid fraud, whenever an offender “uses” the patient’s identity “without lawful authority.” She praised the 4th Circuit’s view that overbilling violates the statute because it is beyond the scope of what the patient authorized.

Either way, “benefits were paid because the criminal used a person’s means of identification as the key to duping the government,” Owen wrote.

Judge Andrew Oldham provided the tenth vote to affirm, but solely on procedural grounds: he said Dubin waited too long to question what constitutes “use” under the identity-theft statute.

“In some future case, where the ‘use’ question is properly preserved, it might be wise for our court to reconsider our interpretation,” Oldham wrote.

Attorneys for both sides did not immediately respond to requests for comment on Wednesday.

The case is USA v. David Fox Dubin, 5th U.S. Circuit Court of Appeals, No. 20-50912.

For the USA: Joseph Gay Jr, Elizabeth Berenguer and Mark Randolph Stelmach of the U.S. Attorney’s Office for the Western District of Texas

For Dubin: Michael Clark Gross of Gross & Esparza; Anton Metlitsky and Jason Zarrow of O’Melveny & Myers

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Clipped from: https://www.reuters.com/legal/litigation/overbilling-medicaid-is-also-aggravated-identity-theft-says-full-5th-circ-2022-03-04/

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Las Vegas healthcare company convicted in Medicaid fraud case

MM Curator summary

[MM Curator Summary]: A behavioral health provider was convicted for submitting false claims and ordered to pay $225,000 back 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.

 
 

The Centers for Medicare and Medicaid Services may now allow for states to pursue Medicaid reimbursements for short-term inpatient treatment in mental health facilities despite a decades-old exclusion, Health and Human Services Secretary Alex Azar announced.

Shutterstock via CNN

LAS VEGAS (FOX5) — Nevada Attorney General Aaron Ford announced the conviction of a Las Vegas medical company for Medicaid fraud.

Kimberly Rashone Broussard, 53, and her company Phenomenal Angels, LLC were sentenced Feb. 28 for Medicaid fraud. 

An investigation alleged that billings submitted by Phenomenal Angels to Medicaid between Jan. 2017 and April 2018 exceeded the maximum number of service hours in a 24-hour period. Investigators found at least two provided purportedly employed by Phenomenal Angels took part in the excess billing hours and Broussard didn’t provide proper documentation supporting the claims.

“Healthcare providers must remain cognizant that the privilege of receiving taxpayer funds for providing services comes with the obligation to maintain accurate records and submit truthful billings to Nevada Medicaid,” said AG Ford. “My office will hold health care companies and their owners accountable for failing to abide by their obligations as approved Nevada Medicaid providers.”

Phenomenal Angels was sentenced for submitting false claims and Broussard was sentenced for intentional failure to maintain adequate records. Broussard was given a 364 day suspended jail sentence and placed on probation for a year. Phenomenal Angels was also ordered to pay nearly $225,000 in restitution.

 
 

Clipped from: https://www.fox5vegas.com/news/crime/las-vegas-healthcare-company-convicted-in-medicaid-fraud-case/article_efc36122-98dd-11ec-a524-4b6e618ac93f.html

 
 

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Improper Medicaid payments expand after ObamaCare and pandemic, studies find

MM Curator summary

[MM Curator Summary]: Payments determined by CMS to be improper range from 22%-37% across states reviewed.

 
 

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.

 
 

As Medicaid rolls have ballooned – becoming the most expensive item in most state budgets – so have improper payments largely driven by ineligible patients that states have been reluctant to remove, according to data released by the Foundation for Government Accountability, a watchdog group.  

As of December 2021, Medicaid had 91 million enrollees – a boost of 18 million people in two years, meaning that a quarter of Americans are on Medicaid, according to the FGA. Of those, 17 million people were ineligible.  

 
 

The number of people on Medicaid, a joint federal and state health insurance program for the poor, has increased almost two and a half times what it was in 2000, putting an accumulated $700 billion strain on state budgets. Much of the increase came after the Medicaid expansion from the Affordable Care Act – better known as ObamaCare – that grew the program by 80% since 2013, according to the FGA findings.  

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“What’s interesting is that most of the improper payment rates are pre-COVID, so we may not know how high the number really is yet,” Hayden Dublois, deputy research director for the Foundation for Government Accountability, told FOX Business. “It’s not a clear red state, blue state divide, but the two highest states for improper payments are states that expanded Medicaid under ObamaCare.” 

The FGA released two recent reports about why this has become such a problem with suggestions about what states can do.  

More than one in five, or 22%, of Medicaid dollars are improperly spent, and that is overwhelmingly due to ineligible people on Medicaid, according to one of the FGA reports.  

 
 

A sampling of states shows some higher than the national average. Ohio’s Medicaid improper payment rate is double the national average at 44%, and 98% of that is caused by ineligible patients.   

Illinois isn’t far behind, with 37%, of which 95% is caused by ineligible patients. In Missouri, a third of the payments are improper, with 70% driven by eligibility errors. For Kansas, it’s 28% improper payments – not that far out of sync with the national average – but the cause is 99% ineligibility errors.   

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Congress passed and former President Trump signed the Families First Coronavirus Response Act, which gave a 6.2% increase in traditional Medicaid funding to states during the COVID-19 pandemic. The extra money was conditioned that states could not change eligibility, adjust the enrollment process, or remove enrollees from the program whether eligible or not until the pandemic is over.  

“According to data from 17 states, roughly 90 percent of all new enrollees during the COVID-19 pandemic are no longer eligible for Medicaid,” one of the FGA reports says. “This means that up to 17 million enrollees nationwide were ineligible by the end of 2021.” 

The FGA has called for states to remove ineligible enrollees – noting that it posed a minimal risk and that the Centers for Medicare and Medicaid Services would not “claw back,” or require states to pay back money from previous cycles. 

 
 

The Medicaid website states that if a state opts out of the extra COVID-19 money requirements it will only lose the extra federal funding for the quarter in which it opts out and remaining quarters until the pandemic end. But it will not have to return the money. FGA urges states, since they face little risk, to work at removing ineligible enrollees from the program.  

“CMS has also never stated that locking ineligible enrollees onto the program is an ongoing condition that could be used to punish a state retroactively,” one of the FGA reports continues.  

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A Centers for Medicare & Medicaid Services spokesperson told FOX Business the agency is committed to transparency and “protecting our program sustainability for future generations.” 

“Improper payment rates are often tied to routine or minor documentation errors and do not necessarily indicate fraud. While any improper payment is unacceptable, the vast majority of improper payments are made with respect to people who may be eligible for care but for whom the state or a provider furnished insufficient documentation to discern if the payment was proper,” the spokesperson said in an emailed statement. “For example, improper payments include both overpayments made by Medicaid, as well as underpayments. Both can result from a variety of circumstances that do not involve fraud – including services with incomplete documentation or insufficient documentation to affirmatively validate that the required verification of eligibility data, such as income, was completed.” 

The CMS spokesperson added that Medicaid is working on regular reporting similar to what helped to reduce improper payments in Medicare, the federal health insurance program for the elderly.  

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“CMS will continue to work with state Medicaid agencies to apply lessons learned from their successful reduction of Medicare Fee-for-Service (FFS) improper payments,” the spokesperson said. 

 
 

Clipped from: https://www.foxbusiness.com/politics/improper-medicaid-payments-expand-obamacare-pandemic-studies 

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FL- Hospital to pay $5.5M to settle improper Medicaid payments case

MM Curator summary

[MM Curator Summary]: A Florida hospital was “donating” services, but then getting federal matching dollars for them, in violation of federal law.

 
 

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.

 
 

NAPLES — NCH Healthcare System, which operates two Collier County hospitals, has agreed to pay the federal government $5.5 million to settle allegations it made donations to local units of government to improperly fund the state’s share of Medicaid payments to NCH.

The claims resolved by the settlement are allegations only and there has been no determination or admission of liability, according to hospital officials and a statement from the U.S. Department of Justice. The case, the DOJ release states, settles “common law allegations for impermissible Medicaid donations.”

In an email response on the case from the Business Observer, a spokesperson with NCH — a nonprofit that cares for more than 40,500 patients in its two hospitals, NCH Baker Hospital Downtown and NCH North Naples Hospital, with a combined 716 beds and some 700 physicians — says the hospital system “fully cooperated with the DOJ.”

“There were other hospitals in Florida similarly situated,” added Shawn McConnell, director of marketing and communications at NCH, in the -mail. “This situation dates back to 2014 and 2015, long before the current administration arrived. This settlement is due to a difference of interpretation of the rules. NCH decided to settle instead of going to court, to avoid spending more time and money.”

Authorities contend that, between October 2014 and September 2015, “NCH made improper, non-bona fide donations by: (1) providing free nursing and athletic training services to the Collier County School Board; and (2) assuming and paying certain of Collier County’s financial obligations,” the release states.

Both types of donations, officials allege, were designed to increase Medicaid payments received by NCH, without any actual expenditure of state or local funds. “In particular, NCH’s donations freed up funds for the county and school board to make payments to the state as the state share of Medicaid payments to NCH,” the release states. This state share was “matched” by the federal government before being returned to NCH as Medicaid payments.

“The Medicaid payments NCH received were thus funded by the federal government and NCH’s own donations, in violation of the prohibition on non-bona fide donations,” the release states.

The Florida Medicaid program provides medical assistance to low-income individuals and individuals with disabilities, and is jointly funded by the federal and state governments. Under federal law, Florida’s share of Medicaid payments must consist of state or local government funds, and not “non-bona fide donations” from private health care providers, such as hospitals. A non-bona fide donation is a payment — in cash or in kind — from a private provider to a governmental entity that is then returned to the private provider as the state share of Medicaid.

The private provider’s donation triggers a corresponding federal expenditure for the federal share of Medicaid, government officials say, which is also paid to the private provider. “This unlawful conduct causes federal expenditures to increase without any corresponding increase in state expenditures, since the state share of the Medicaid payments to the provider comes from and is returned to the provider,” the release states.

The prohibition of this practice, officials say, ensures that states are in fact paying a share of Medicaid payments and thus have an incentive to curb Medicaid costs and prevent unnecessary services.

“States and local units of government must use their own money when seeking federal Medicaid matching funds to help ensure that Medicaid payments are determined by beneficiaries’ medical needs rather than donations by hospitals or other health care providers,” Acting Assistant Attorney General Brian Boynton of the Justice Department’s Civil Division says in the release. “When private parties violate the rules by making improper donations to fund the state share of Medicaid, they endanger the integrity of the Medicaid program.”

“Millions of Floridians depend on the Medicaid Program for medical care and related services,” adds U.S. Attorney Roger Handberg for the Middle District of Florida, in Tampa, in the release. “This settlement underscores our commitment to protecting the integrity of the Medicaid program by ensuring that government funds are legally obtained and used for their intended purposes.” 

The resolution of the case was the result of a coordinated effort between the Justice Department’s Civil Division, Commercial Litigation Branch, Fraud Section and the U.S. Attorney’s Office for the Middle District of Florida, with assistance from the U.S. Department of Health and Human Services Office of Inspector General.

 
 

Clipped from: https://www.businessobserverfl.com/article/hospital-to-pay-5-5m-to-settle-improper-medicaid-payments-case