Tag: State News
PHE- Navigating the New FMAP Glidepath – FMAP Changes in the Consolidated Appropriations Act of 2023
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]: There is now a schedule of decreasing FMAP to land the plane by year end. Sort of. If you follow all the rules exactly like CMS says you should (think Van Halen and green M&Ms).
Clipped from: https://www.dentons.com/en/insights/alerts/2023/january/5/navigating-the-new-fmap-glidepath
In response to the COVID-19 pandemic and the expected economic downturn, Section 6008 of the Families First Coronavirus Response Act of 2020 (Families First) established a temporary 6.2% increase in the Medicaid federal medical assistance percentage (FMAP), effective January 1, 2020, to last through the last day of the calendar quarter in which the COVID-19 public health emergency (PHE) ended. One condition of the FMAP increase was a prohibition on Medicaid disenrollment during the PHE.
The Consolidated Appropriations Act of 2023 (Pub. L. 117-328) – enacted over the holidays – makes several notable changes to the FMAP increase and related Medicaid eligibility redetermination and disenrollment requirements. Although these FMAP changes are obviously important to States, they are also important to providers and local government entities that may be funding the non-federal share of Medicaid payments through intergovernmental transfers or provider taxes.
FMAP Increase Transition Period
Section 5131 of Division FF of the Consolidated Appropriations Act of 2023 establishes a “transition period” for the Families First FMAP increase:
Time periodIncrease
|
|
|
|
January 1, 2020 through March 31, 2023 |
6.2 percent |
|
April 1, 2023 through June 30, 2023 |
5 percent |
|
July 1, 2023 through September 30, 2023 |
2.5 percent |
|
October 1, 2023 through December 31, 2023 |
1.5 percent |
New Conditions
Section 5131 also imposes new conditions on States’ receipt of the enhanced FMAP during the transition period beginning April 1, 2023. In particular:
Eligibility Redeterminations.— A State that fails to meet any of the following conditions will not qualify for the FMAP increase for the applicable calendar quarter:
- Eligibility redeterminations must be in accordance with all Federal requirements.
- The State must attempt to ensure up-to-date contact information (including a mailing address, phone number, and email address) for each eligibility redetermination using the National Change of Address Database Maintained by the United States Postal Service, State health and human services agencies, or other reliable sources of contact information.
- The State may not disenroll any individual based on returned mail unless the State first undertakes a good faith effort to contact the individual using more than one modality.
Note that these requirements do not prohibit a State from initiating renewals, post-enrollment verifications, and redeterminations over a 12-month period for all individuals who are enrolled in the State’s Medicaid program as of April 1, 2023.
Reporting Requirements.—The FMAP for a State that does not satisfy new reporting requirements will be reduced by 0.25 percentage points times the number of fiscal quarters for which the State has failed to satisfy such requirements, although the reduction can be no greater than 1 percentage point. Specifically, beginning April 1, 2023 and lasting through June 30, 2024, each State will be required to submit monthly reports to the Department of Health and Human Services (HHS) on the State’s activities relating to eligibility redeterminations, including, but not limited to, the number of eligibility renewals initiated and the number of individuals whose Medicaid coverage was terminated. These reports will be publicly available.
In addition, if HHS determines that a State did not comply with eligibility redetermination and reporting requirements during the April 1, 2023 to June 30, 2024 period, HHS may, in addition to other remedies, require that the State submit and implement a corrective action plan. If a State fails to submit or implement an approved corrective action plan, HHS may require the State suspend making all or some eligibility terminations and may impose civil money penalties of up to $100,000 per day.
MCOs, CA- Medi-Cal adds more insurance plans after pushback
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]: Move the L for CA community plans to the W column.
Clipped from: https://calmatters.org/health/2023/01/medi-cal-insurance-plans/
In summary
State health officials last year launched a first-ever competitive bidding process for its Medi-Cal insurance contracts, aiming to implement higher standards. But when the winners were announced, several insurers complained about the process and potential impact on patient care.
Lea este artículo en español.
In a significant course change, the California Department of Health Care Services announced that it has negotiated with five commercial health plans to provide Medi-Cal services in 2024, scratching a two-year-long bidding process for the coveted state contracts.
This upends the state’s previous plans of awarding contracts to only three health plans. It means more Medi-Cal enrollees will likely get to keep their current insurer and doctors, averting a confusing re-enrollment process for most members and preventing disruption to patient care. It also means that the state will avoid a protracted legal battle amid lawsuit threats from insurers who had previously been left out.
The big winners: Blue Shield and Community Health Group will get a contract after initially having lost bids, and Health Net will get to keep at least some of its Los Angeles enrollees.
“To bring certainty for members, providers and plans, the State used its authority to work directly with the plans to re-chart our partnership and move with confidence and speed toward the implementation of the changes we want to see,” the department wrote in a statement released Friday afternoon. The department did not provide answers to follow-up questions before publication.
“At some level it makes the transition easier, but we want to do better than the status quo,” said Anthony Wright, executive director of Health Access, a consumer advocacy group. “Less disruption is good, but we don’t want to lose the reason for the change, which is to have more accountability on these plans going forward.”
Loading…
Medi-Cal provides health coverage to more than 14 million low-income Californians, more than a third of the state’s population. In 2021, the Department of Health Care Services, which oversees the Medi-Cal program, embarked on a bidding process that would allow it to rework contracts with commercial Medi-Cal health plans. The state’s goal was to reduce the number of participating health plans from the current nine and move forward with only the most qualified plans, which would be held to higher standards related to patient outcomes, wait times and satisfaction, as well as improving health disparities.
In August of last year, the state announced that it would tentatively award $14 billion worth of Medi-Cal contracts to three companies — Health Net, Molina and Anthem Blue Cross. This proposed decision would force close to 2 million Medi-Cal enrollees to switch insurance and likely find new providers. Some health providers decried the department’s original contract decision, claiming it would have caused “immeasurable” disruption to care.
“Less disruption is good, but we don’t want to lose the reason for the change, which is to have more accountability.”
Anthony Wright, executive director of Health Access
Kaiser Permanente negotiated a special contract with the state early last year, bypassing the bidding process. And most nonprofit community-based health plans did not have to compete for a contract.
The state’s summer announcement quickly became controversial as health plans that were left out questioned the state’s process for choosing the three insurers, appealed the decision and sued the state.
This change of course calls into question the power that insurance companies can have in pressuring state action with legal threats. Health advocates say they hope it does not set a precedent. Wright at Health Access said he’d like for the department to make clear that the state is not backing away from the competitive contract process in the future, as he considers it is a key tool for accountability.
Blue Shield, one of the insurance companies initially left out, filed a complaint against the Department of Health Care Services, requesting that the department release all documents used in the selection process.
The insurance giant even launched a campaign in the fall asking Californians to speak out against the state’s decision. The company argued that the state failed to sufficiently engage Medi-Cal enrollees and doctors in the process. “The message of this campaign is that it’s not too late for the state to change course and make choices that will advance innovation and health equity for everyone,” Kristen Cerf, president and CEO of Blue Shield’s Medi-Cal plan, said in a statement in October.
Under the revised agreement, Blue Shield will get to keep serving the San Diego area. Blue Shield declined a request for an interview, instead referring reporters to a statement released Tuesday.
Meanwhile, Health Net, which in the summer was tentatively awarded contracts in nine counties but lost its previous and largest contract in Los Angeles, also sued the state. Under the new agreement, Health Net will get to stay in Los Angeles and will divide its share of Medi-Cal enrollees evenly with its commercial counterpart, Molina Healthcare. Health Net will also keep its Sacramento membership but lose the San Diego market.
Centene, the parent company of Health Net, said in a Tuesday statement that it would end its legal actions against the state’s health services department.
The splitting of members evenly between Molina and Health Net through a subcontracting agreement is a “step in the right direction,” said Jim Mangia, president and CEO of St. John’s Community Health, which serves low-income patients in south LA, but much remains uncertain.
“Who’s the 50 percent that are going to be able to stay with Health Net and who are the 50 percent that are going to have to move?” Mangia said. “We don’t have answers to that, so I think it’s problematic in that it still displaces a significant number of patients.”
Currently, Health Net manages more than 1 million Medi-Cal patients in Los Angeles County. Nearly a quarter of St. John’s Community Health patients have Health Net, with the publicly run L.A. Care Health Plan accounting for the rest. (Most Angelenos with Medi-Cal are enrolled in and will be able to continue with L.A. Care, a publicly operated plan.)
Mangia said the latest decision will still disrupt services for the 12,500 patients at St. John’s alone who will be forced to switch to Molina. He anticipates the clinic needing to hire more staff to help with patient navigation, but there’s no money for that.
“It was obviously an attempt to rectify the initial decision, but I’m not sure the impact on patients is going to be all that different. That’s my concern,” Mangia said. “It’s essentially an unfunded mandate.”
“Who’s the 50 percent that are going to be able to stay with Health Net and who are the 50 percent that are going to have to move?”
Jim Mangia, president and CEO of St. John’s Community Health
Health Net and Molina Healthcare did not reply to requests for comment, but in an early Tuesday morning call with investors, Molina CEO Joseph Zubretsky characterized the state’s final decision as “taking three steps forward, taking one step back” for the company, which had originally hoped to triple its Medi-Cal membership under the tentative award announced in August.
In discussing the decision, Zubretsky and CFO Mark Keim alluded to closed-door negotiations between Molina, the state health care services department and the appealing insurers. When asked whether the state ever considered restarting the bidding process, Zubretsky said California regulators had “broad discretionary authority” to award contracts and new bids could have taken a significant amount of time.
“With that as the understanding, we thought it best for the company, for membership and for investors to participate in the negotiation,” Zubretsky said.
Molina has agreed not to protest the final contract award and will subcontract with Health Net in Los Angeles County in the “negotiated settlement,” Zubretsky said. Molina will double its Medi-Cal membership — from 600,000 to 1.2 million — by 2024 as a result of this latest contract.
“We’ve agreed to the membership allocations that the state has now articulated in addition to waiving other types of legal rights that one would normally have,” Zubretsky told investors.
Community Health Group, the largest Medi-Cal provider in San Diego County, will also get a new contract in 2024. The insurer was excluded in the original summer announcement, but appealed the state’s decision.
Community Health Group declined an interview request, but over the summer, the company’s chief operating officer, Joseph Garcia, told CalMatters that the state’s decision had been shocking because his company routinely outperformed other insurers.
Zara Marselian, CEO of La Maestra Community Health Centers in San Diego, said the state’s new decision was a welcome surprise. La Maestra’s clinics serve low-income patients throughout the county and have worked with Community Health Group for nearly three decades. About 26% of its patients rely on Community Health Group for Medi-Cal, the most of any single patient group. Previously, Marselian had also predicted having to hire more staff to help patients navigate the transition.
“It’s really better for the Medi-Cal recipients that will not now have to transfer to another health plan and have their whole continuity of care disrupted,” Marselian said. “I’m really grateful however this happened. I’m really grateful on behalf of our patients.”
We want to hear from you
Want to submit a guest commentary or reaction to an article we wrote? You can find our submission guidelines here. Please contact CalMatters with any commentary questions: commentary@calmatters.org
MCOs; PayVider- JPM23: CVS weighs next steps in its primary care ambitions
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]: CVS may or may not buy up Oak Street Health to continue its march deeper down the PayVider path.
Clipped from: https://www.fiercehealthcare.com/payers/jpm23-cvs-health-still-weighing-next-steps-its-plans-foray-primary-care
SAN FRANCISCO—The top brass at CVS Health reiterated Tuesday that the healthcare giant is still plotting its move into primary care but emphasized that they want to ensure the next steps are the right ones.
CVS presented early on the second day of the J.P. Morgan Healthcare Conference as media reports circled that its primary care target could be Oak Street Health. Bloomberg reported that a $10 billion deal could be reached in weeks, citing people familiar with the negotiations.
However, Bloomberg’s sources did note that the ongoing talks between the companies could end without a deal in place.
For her part, CVS CEO Karen Lynch did not address the reported conversations with Oak Street Health. She said that while the company is still planning its push into primary care, it doesn’t want to act hastily.
“What we’ve been very clear about is we want to make sure it’s the right asset at the right time,” she said. “This isn’t a one-and-done.”
Lynch said during the company’s second-quarter earnings call in August that CVS was planning to get some kind of primary care deal on the books by the end of 2022. It reportedly courted and was rejected by concierge care provider One Medical, which is in the process of being bought out by Amazon.
Instead, it announced plans to acquire Signify Health, a move that instead enhances CVS’ capabilities in home health and value-based care.
The $8 billion deal is currently under regulatory review, and Lynch said the company expects it to close in the first half of 2023.
Signify’s strengths also align with key priorities at CVS, she said, as home health is the “future of healthcare,” and the company is aiming to make a greater push into enabling value-based care. A tightrope the company had to walk, though, is working with its competitors such as Humana that are also existing Signify clients.
Lynch said that as major insurers become increasingly diverse and vertically integrated, they’ve had to navigate the combination of direct competitors who are also clientele.
“As we think about the industry, we’re all kind of working with each other, and we’re all kind of customers of each other,” she said. “We’ve committed to them to be payer agnostic, and we think that’s how the industry will evolve over time.”
The Signify deal also brings with it Caravan Health, which is built to assist in establishing accountable care programs and was scooped up by Signify in early 2022. Lynch said Caravan’s capabilities will be critical to CVS’ ambitions in the provider space moving forward.
Chief Financial Officer Shawn Guertin added that the company’s plans around primary care also feed back into its focus on value-based care, as effective, accessible primary care is central to the care continuum.
“This is the first leg of the stool in our longer strategy,” Lynch said.
FWA NC- Charlotte man convicted in multimillion-dollar Medicaid 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]: Donald Booker stole $11M from NC using bogus drug testing and mental health services claims.
Clipped from: https://www.wfae.org/crime-justice/2023-01-11/charlotte-man-convicted-in-multimillion-dollar-medicaid-scheme
A jury convicted Charlotte man Donald Booker, 57, of federal charges in connection with a scheme that fraudulently took more than $11 million from the North Carolina Medicaid program, prosecutors said this week.
According to court filings and trial testimony, Booker was the owner of Diagnostic Laboratories, a urine toxicology testing laboratory, and United Youth Care Services, a company that provided mental health and substance abuse treatment services.
His co-defendant, Delores Jordan, pleaded guilty in December. Jordan owned housing provider Legacy Housing.
From January 2016 to August 2019, Booker and Jordan worked with others to defraud the NC Medicaid program, prosecutors said. They said Jordan enrolled vulnerable and Medicaid-income people for housing benefits and other services, and then referred them to Booker’s company for “medically unnecessary” urine screens and drug tests. Booker then paid kickbacks to Jordan and other co-conspirators in exchange for the business, prosecutors said.
SUPPORT LOCAL NEWS
As a nonprofit newsroom, WFAE relies on readers like you to make stories like this possible. Our local reporting is vital to the health of our communities and our democracy, but we can’t do this without you. Please consider supporting our journalism by contributing as little as $10 today.
The jury convicted Booker of conspiracy to commit healthcare fraud, multiple violations of Anti Kickback Statute, money laundering conspiracy and money laundering.
Jordan pleaded guilty to healthcare fraud conspiracy and money laundering conspiracy.
Their sentencing dates have not been set.
The investigation was conducted by the FBI, IRS and NC Medicaid Investigations Division.
“I’m grateful to our federal and state partners for helping bring this person to account,” said Attorney General Josh Stein. “Medicaid resources belong to the taxpayers, and we’ll hold accountable anyone who defrauds the program.”
Sign up for our daily headlines newsletter
Email Address
- The Frequency – The latest WFAE stories each weekday morning.
Select Your Email Format
- html
- text
FWA- District of South Carolina | Greer Man Sentenced in Multimillion Dollar South Carolina Medicaid 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]: Jonathan Sumter stole $1M using a fake behavioral health company that never actually had any clients or providers.
Clipped from: https://www.justice.gov/usao-sc/pr/greer-man-sentenced-multimillion-dollar-south-carolina-medicaid-scheme
Columbia, South Carolina – Jonathan W. Sumter, 51, of Greer, was sentenced to over 7 years in federal prison after pleading guilty in a case of theft of government funds for his scheme to defraud South Carolina Medicaid of over $1 million.
According to evidence presented to the Court, Sumter founded PHC Supportive Services as a company supposedly providing rehabilitative behavioral health services to disabled, low-income individuals in South Carolina through the Medicaid program. Instead, between 2015 and 2019, the company billed South Carolina Medicaid over one million dollars for services never performed.
The Government provided evidence that PHC never had any actual clients or service providers. Instead, Sumter repeatedly billed Medicaid by using the stolen National Provider Identifier (NPI) numbers of nine health care professionals to create fraudulent invoices to Medicaid. Sumter then used the stolen identities of 196 Medicaid members with severe mental and emotional health disorders without their knowledge or consent. Caregivers and clients contacted by investigators indicated that they had never received any services from Sumter or PHC. Additionally, the service providers Sumter used on his invoices indicated that they did not work for PHC and had not provided medical services for the company.
“Using stolen identifies of the most defenseless people to steal money from the hard-working people of South Carolina is unacceptable. We will continue to aggressively prosecute offenders who steal from programs designed to provide sorely needed care for our most vulnerable citizens,” said U.S. Attorney Adair Boroughs.
“This sentence warns bad actors in the behavioral healthcare field that South Carolina has citizens in need of these services; any fraudulent conduct that abuses these programs or prevents our citizens from receiving needed services will not be tolerated. Our office will continue to partner with the United States Attorney’s Office for the arrest and prosecution of those committing fraud against the Medicaid program. We thank our law enforcement partners at the United States Department of Health and Human Services’ Office of the Inspector General for their partnership during this investigation,” Attorney General Alan Wilson said.
United States District Judge Donald C. Coggins sentenced Sumter to 92 months in prison. Sumter was also ordered to repay $1,055,373.66 in restitution to South Carolina Medicaid.
The case was investigated by the United States Department of Health and Human Services and the South Carolina Attorney General’s Office. It was prosecuted by Assistant United States Attorney T. DeWayne Pearson.
###
FWA MS- Mitias to pay $1.87 Million to settle allegations of Medicare and Medicaid overbilling
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]: Hanna Mitias stole $1.9M by substituting cheap knee injection drugs for more expensive ones he billed for.
Clipped from: https://www.oxfordeagle.com/2023/01/11/mitias-to-pay-1-87-million-to-settle-allegations-of-medicare-and-medicaid-overbilling/
Published 4:30 pm Wednesday, January 11, 2023
By Staff Report
The Nothern Mississippi Department of Justice
Mitias Orthopaedics, PLLC, it’s owner Dr. Hanna “Johnny” Mitias, and a subsidiary Champion Orthopedics, have agreed to pay $1,870,714.83 to resolve allegations the orthopedic health services providers knowingly submitted false claims to Medicare and Medicaid, the Department of Justice announced today.
“Taxpayers deserve to receive the products and services billed to their federal health insurance programs. The viability of Medicare and Medicaid is threatened by each wasted dollar. Our people come before profits,” said United States Attorney Clay Joyner. “This settlement sends a clear message that the Department of Justice will hold healthcare providers accountable if they knowingly overbill federal healthcare programs.”
Between Jan. 1, 2008, and Dec. 31, 2015, Mitias and his clinics allegedly submitted false claims to the Medicare and Medicaid programs for brand name viscosupplementation agents for knee injections that were not administered to the beneficiaries of those programs. Rather, a much cheaper, compounded viscosupplementation agent was alleged to have been used and, as a result, the defendants improperly claimed compensation for the higher priced products.
Email newsletter signup
Sign up for our daily email newsletter
“We are committed to thoroughly investigating claims of fraud and holding health care providers accountable when they break the rules. The public should know we will devote the necessary time and effort to stamp out healthcare fraud in both civil and criminal matters,” said Joyner. “This settlement is an example of how whistleblowers and the government can work together to recoup and deter overbilling practices.”
The settlement resolves allegations in a 2015 lawsuit by a medical device sales representative filed under the whistleblower provisions of the False Claims Act. Those provisions permit private individuals to sue on behalf of the government for false claims and to share in any recovery.
The settlement was the result of a coordinated effort by the Civil Division of the Department of Justice, the United States Attorney’s Office for the Northern District of Mississippi, the Department of Health & Human Services, Office of Inspector General, and the State of Mississippi Attorney General’s Office Medicaid Fraud Control Unit.
The case is captioned United States ex rel. Gray v. Mitias Orthopaedics, PLLC (3:15-cv-127). The claims resolved by the settlement are allegations only and there has been no determination of liability.
FWA MI- Three men charged with millions in Medicare, Medicaid fraud
MM Curator summary
The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.
[MM Curator Summary]: John, Rob and Richard stole $44M using a kickback scheme to drive revenues for their genetic testing lab.
Clipped from: https://www.upi.com/Top_News/US/2023/01/06/justice-department-charges-fraud-medicare-medicaid/7701673039406/
1/2
Jan. 6 (UPI) — Three men have been charged with conspiring to defraud the federal government out of more than $107 million after submitting fraudulent genetic testing claims to Medicare.
A superseding indictment was opened Friday, charging John Grisham and Rob Wilburn, of Texas, and Richard Speights Jr., of Louisiana, the Justice Department said in a release.
The three men allegedly owned and operated a genetic testing laboratory in Lewisville, Texas between January 2018 and October 2019.
They are accused of acquiring thousands of Medicare beneficiaries’ DNA specimens and corresponding prescriptions, which Trinity Clinical Laboratories then used to fraudulently bill Medicare and Medicare Advantage for genetic testing.
RELATED Former Arkansas judge arrested
The sophisticated and nationwide health care kickback scheme allegedly netted some $44 million worth of Medicare reimbursements “due to the defendants’ payment and receipt of kickbacks and bribes,” according to the Justice Department.
Following a multi-agency investigation, all three men are now facing one count of conspiracy to defraud the United States and to pay and receive kickbacks and bribes.
Additionally, Grisham, 49, and Wilburn, 51, are each charged with six counts, and Speights Jr.,52, is charged with two counts of paying and receiving health care kickbacks and bribes.
If convicted, the men face 10 years in prison on each count of paying and receiving health care kickbacks and bribes and five years incarceration on the conspiracy count.
The investigation came under the umbrella of the national Health Care Fraud Strike Force Program.
Since March 2007, the program has charged more than 4,200 defendants who collectively have billed the Medicare program for more than $19 billion.
In November, the Justice Department charged 10 individuals in multiple states for defrauding healthcare providers, insurance companies, Medicare and Medicaid.
Read More
‘Romeo and Juliet’ stars sue Paramount for child abuse over 1968 nude scene
FWA NY- Former Executive Director of Long Island Charity Sentenced to Over Two Years in Prison for Embezzlement
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]: Wafa Abboud used her non-profit to steal $1.4M by hiding monthly “consulting” payments to herself.
Clipped from: https://www.justice.gov/usao-edny/pr/former-executive-director-long-island-charity-sentenced-over-two-years-prison
Defendant and Co-Conspirators Used Multiple Schemes to Steal Over $1 Million from Non-Profit Agency Devoted to Assisting Developmentally Disabled Youth, Spending the Funds on Luxury Items
Earlier today, at the federal courthouse in Brooklyn, Senior United States District Judge Edward R. Korman sentenced Wafa Abboud to a term of imprisonment of 33 months. As part of the sentence, Judge Korman also ordered Abboud to forfeit $836,000 and pay $1,415,000 in restitution to Human First, Inc. (Human First), the nonprofit agency that Abboud led for more than five years. Abboud was convicted following a two-week jury trial in July 2019 of theft from programs receiving federal funds, bank fraud, and conspiracies to commit those crimes.
Breon Peace, United States Attorney for the Eastern District of New York, announced the sentence.
“Stealing taxpayer money earmarked for developmentally disabled youth to pay for vacations, cosmetic surgery, and luxurious vacations is shameful,” stated United States Attorney Peace. “Today, the defendant has been held accountable for betraying the most vulnerable among us whom she was entrusted to serve and treating the non-profit organization bank accounts as though they were her own.”
Mr. Peace thanked the Federal Bureau of Investigation, New York Field Office, for its investigative work on the case.
From January 2011 until her termination on May 27, 2016, Abboud was the Executive Director of Human First, a non-profit corporation that provided services to individuals with autism and other developmental disabilities. In that capacity, Abboud exercised nearly complete control over the charity’s finances. During Abboud’s tenure, Human First received tens of millions of dollars annually from the New York State Office for People with Development Disabilities, which is funded in significant part by the Medicaid program. The money was disbursed to Human First to support its mission of providing residential, rehabilitative, and other services to developmentally disabled youth.
Abboud entered into an agreement with co-defendant Marcelle Bailey whereby Abboud caused Human First to pay Bailey’s company MPB Management Services LLC (MPB) approximately $16,000 per month in purported “consulting” fees. Bailey deposited approximately half of each monthly disbursement into bank accounts that were controlled by Abboud, who used the money to fund a lavish lifestyle, including expensive international vacations, visits to luxury spas and high-end beauty salons and restaurants, and elective cosmetic surgeries. Abboud also withdrew approximately $120,000 from the accounts in cash and wired tens of thousands of dollars in the account overseas. In total, Abboud stole approximately $420,000 between May 2011 and February 2016 through the MPB embezzlement scheme.
Abboud also conspired with co-defendant Rami Taha to steal over $400,000 through a scheme in which Abboud deliberately issued overpayments to contractors performing work on Human First properties with the knowledge that the overpayment would be kicked back to her. The overpayments were disguised through the use of inflated invoices submitted to Human First, and the payments to Abboud were hidden by transferring the funds through a number of sham bank accounts before ultimately depositing them into accounts controlled by Abboud. Abboud used the stolen money to finance the down payment and renovation of her residence. To conceal the true source of the funds, Abboud lied to her mortgage lender, falsely claiming that the funds were a settlement payment she had received for damage caused to her previous home.
Bailey pleaded guilty to embezzlement and bank fraud in December 2017 and was sentenced by Judge Korman in August 2021 to 33 months in prison. Taha pleaded guilty in May 2019 to embezzlement. A fourth defendant, Arkadiusz Swiechowicz, pleaded guilty to obstruction of justice in September 2018. Taha and Swiechowicz are awaiting sentencing.
The government’s case is being handled by the Office’s Public Integrity Section. Assistant United States Attorneys Robert Polemeni and Turner Buford are in charge of the prosecution. Assistant United States Attorney Tanisha Payne of the Office’s Asset Recovery Section is handling forfeiture matters in the case.
The Defendant:
WAFA ABBOUD
Age: 55
Merrick, NY
E.D.N.Y. Docket No. 16-CR-396 (ERK)
FWA; DE- Delaware to Receive Nearly $56,000 for Alleged False Claims Caused by Respiratory-Related Medical Equipment
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]: Phillips RS North America will pay $24M for its scam that paid DME companies kickbacks in the form of data that was valuable for marketing and sales.
Delaware News
Flag Status – FULL STAFF
Delaware has joined with other states and the federal government to reach an agreement in principle with Philips RS North America LLC, (formerly known as Respironics Inc.), a manufacturer of durable medical equipment (DME) based in Pittsburgh, Pennsylvania, to resolve federal False Claims Act and Delaware False Claims and Reporting Act (DFCRA) allegations that it misled federal health care programs by paying kickbacks to DME suppliers.
Respironics has agreed to pay over $24 million to resolve the allegations that affected Medicare, Medicaid and TRICARE, which is the health care program for active military and their families. Of the total settlement amount, $4,826,250.00 will go to the Medicaid program. Delaware’s Medicaid program will receive $55,688.54.
“Kickbacks result in improper claims being filed with Medicaid and other healthcare benefit programs, and drain precious resources that Medicaid recipients rely on,” Attorney General Jennings said. “We will continue fighting against fraud, waste, and abuse against the government.”
The settlement resolves allegations that from November 1, 2014 through April 30, 2020, that Respironics caused DME suppliers to submit false claims to the Medicaid program for ventilators, oxygen concentrators, CPAP and BiPAP machines, and other respiratory-related medical equipment, when such claims were tainted by Respironics’ providing unlawful remuneration to these DME suppliers in the form of physician prescribing data (known as “HMS” or “Health Market Science data”), free of charge, knowing that this data may be of significant value to DME suppliers in their own marketing efforts.
This settlement arises from a qui tam action originally filed in October of 2019 and then amended in November of 2019 in the United States District Court for the District of South Carolina under the federal False Claims Act and various states’ statutes, including the DFCRA.
Delaware, along with representatives from the Offices of the Attorneys General for the states of Florida, Illinois, Indiana, New York, Pennsylvania, Tennessee, and Washington, assisted in leading a National Association of Medicaid Fraud Control Units (NAMFCU) team during the investigation and settlement negotiations with Respironics on behalf of the states.
The Attorney General’s Medicaid Fraud Control Unit receives 75 percent of its funding from the U.S. Department of Health and Human Services under a grant award totaling $2,023,800 for Federal FY 2022. The remaining 25 percent, totaling $674,595 for FY 2022, is funded by Delaware.
Keep up to date by receiving a daily digest email, around noon, of current news release posts from state agencies on news.delaware.gov.
Here you can subscribe to future news updates.
Delaware to Receive Nearly $56,000 for Alleged False Claims Caused by Respiratory-Related Medical Equipment
Featured Posts | News | Date Posted: Wednesday, January 11, 2023
Delaware has joined with other states and the federal government to reach an agreement in principle with Philips RS North America LLC, (formerly known as Respironics Inc.), a manufacturer of durable medical equipment (DME) based in Pittsburgh, Pennsylvania, to resolve federal False Claims Act and Delaware False Claims and Reporting Act (DFCRA) allegations that it misled federal health care programs by paying kickbacks to DME suppliers.
Respironics has agreed to pay over $24 million to resolve the allegations that affected Medicare, Medicaid and TRICARE, which is the health care program for active military and their families. Of the total settlement amount, $4,826,250.00 will go to the Medicaid program. Delaware’s Medicaid program will receive $55,688.54.
“Kickbacks result in improper claims being filed with Medicaid and other healthcare benefit programs, and drain precious resources that Medicaid recipients rely on,” Attorney General Jennings said. “We will continue fighting against fraud, waste, and abuse against the government.”
The settlement resolves allegations that from November 1, 2014 through April 30, 2020, that Respironics caused DME suppliers to submit false claims to the Medicaid program for ventilators, oxygen concentrators, CPAP and BiPAP machines, and other respiratory-related medical equipment, when such claims were tainted by Respironics’ providing unlawful remuneration to these DME suppliers in the form of physician prescribing data (known as “HMS” or “Health Market Science data”), free of charge, knowing that this data may be of significant value to DME suppliers in their own marketing efforts.
This settlement arises from a qui tam action originally filed in October of 2019 and then amended in November of 2019 in the United States District Court for the District of South Carolina under the federal False Claims Act and various states’ statutes, including the DFCRA.
Delaware, along with representatives from the Offices of the Attorneys General for the states of Florida, Illinois, Indiana, New York, Pennsylvania, Tennessee, and Washington, assisted in leading a National Association of Medicaid Fraud Control Units (NAMFCU) team during the investigation and settlement negotiations with Respironics on behalf of the states.
The Attorney General’s Medicaid Fraud Control Unit receives 75 percent of its funding from the U.S. Department of Health and Human Services under a grant award totaling $2,023,800 for Federal FY 2022. The remaining 25 percent, totaling $674,595 for FY 2022, is funded by Delaware.
Keep up to date by receiving a daily digest email, around noon, of current news release posts from state agencies on news.delaware.gov.
Here you can subscribe to future news updates.