Tag: State News

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

[MM Curator Summary]: Another facility got caught helping an MCO inflate its MLR.

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

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

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

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

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

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

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

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

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

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

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

The investigation of this matter illustrates the government’s emphasis on combating healthcare fraud.  One of the most powerful tools in this effort is the False Claims Act.  Tips and complaints from all sources about potential fraud, waste, abuse, and mismanagement, can be reported to the Department of Health and Human Services at 800-HHS-TIPS (800-447-8477).

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

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

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

[MM Curator Summary]: Pretty big for a personal care assistant scheme.

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

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

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

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

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

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

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

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

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

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

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

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

MM Curator summary

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

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

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

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

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

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

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

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

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

$1,267,500.

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

The investigation and resolution of this matter illustrates the government’s emphasis on combating health care fraud. One of the most powerful tools in this effort is the False Claims Act. Tips and complaints from all sources about potential fraud, waste, abuse, and mismanagement can be reported to the Department of Health and Human Services at 800- HHS-TIPS (800-447-8477).

MM Curator summary

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

[MM Curator Summary]: One provider let another provider use their billing ID- for a 25% cut. You paid $338k for it.

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

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

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

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

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

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

Tomczak is released on bond pending sentencing.

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

MM Curator summary

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

[MM Curator Summary]: Another bogus NEMT scheme. And another story of Medicaid members taking kickbacks to make it happen.

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

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

August 28, 2023

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

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

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

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

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

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

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

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

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

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

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

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

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

MM Curator summary

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

[MM Curator Summary]: $900k stolen for a bogus ABA scam.

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

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

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

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

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

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

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