Twenty-Five People Charged in Massive DC Medicaid Fraud Case
March 11, 2014 08:14 AM
In what the FBI is calling “the largest health care fraud takedown in the history of the District of Columbia,” late last month, federal authorities arrested and charged 25 people with Medicaid fraud. Twelve defendants were charged in the U.S. District Court for the District of Columbia (“District Court”), while another 13 defendants were charged with first-degree fraud in the Superior Court of the District of Columbia (“Superior Court”). The alleged schemes included the following:
Billing for services not rendered to Maryland and DC Medicaid programs, totaling $78 million in fraudulent claims;
Cooperation with beneficiaries to commit beneficiary fraud for services not rendered; and
Sale of fraudulent home health care aide certificates
District Court Cases
Some of the District Court cases include the following:
Florence Bikundi, an owner of three home care agencies, was charged with Medicaid fraud, health care fraud, and other charges. Specifically, from July 2007 through the present, she received $75 million in Medicaid payments from DC and $3 million in Medicaid payments from Maryland while barred from participation in any federal health care program. She had been barred in April 2000 after having her nursing license revoked in Virginia.
When later obtaining Medicaid provider numbers for her businesses, she did not disclose that she had her nursing license revoked in Virginia, the District of Columbia, and South Carolina. She also used a different last name to obtain these provider numbers from the name mentioned in the exclusion.
Arrey Kingsly Etchi-Banyi was one of five charged with Medicaid fraud, health care fraud, and other charges. Specifically, he and four others received $498,000 in fraudulent payments from DC Medicaid. An owner of a Maryland nurse staffing agency, Etchi-Banyi allegedly conspired with the other four defendants to obtain fraudulent personal care services payments between February 2012 and October 2013. The five enrolled at least 19 beneficiaries with kickbacks to falsely present themselves as eligible to doctors and to prepare false timesheets.
Felix Aburi Fon and another personal care aide (his wife), employees of a DC home care agency, were charged with Medicaid fraud, health care fraud, and other charges for allegedly receiving $124,000 in fraudulent Medicaid payments from DC. From April 2012 through September 2013, the two offered kickbacks to beneficiaries to submit false timesheets.
Adoshia L. Flythe, an employee of a DC home care agency, was charged for counterfeiting “Home Health Care Aide” certificates and “Health Certificate[s] for Staff,” requisites for being a personal care aide in DC.
For details on these cases, in addition to others including the Superior Court cases, see the FBI press release here.
As Medicaid home care spending increases, anti-fraud efforts have focused more resources in a variety of “risk areas.” Recent prosecutions have highlighted serious program integrity weaknesses in both consumer-directed and agency models of home care. These prosecutions include many cases of billing for services never rendered and include allegations of beneficiary complicity as well. Often family members are involved.
It appears that the concerns with billing for services never rendered are especially acute in consumer-directed care programs. While these types of home care delivery models provide an important level of control to the client, they also run a higher risk of fraud, particularly where the caregivers are from the client’s family. These risks may provide home care agencies with an opportunity to supply some program integrity oversight along with caregiver training and supervision. At the same time, agencies should guard against Medicaid programs promulgating new regulatory measures that affect agency-model and consumer directed care equally.
It can be anticipated that investigations and prosecutions will continue for some time to come as states share information and strategies. Home care companies doing business with Medicaid would be well served if they redouble their internal program integrity efforts. Home care companies should use service attendance and documentation systems that provide reliable ways to validate any self-submitted information. Further, agencies should engage in at least spot checks with recipients to ensure actual delivery of care and continued eligibility for services. In many circumstances, Medicaid will attempt to recover any fraudulent payments from the agency even if the agency is not implicated in the fraud. In addition, the fraud of an employee can create a risk that the employer is also charged with fraud. Home care companies should anticipate future regulatory and legislative action to stem the growing instances of home care fraud, as is seemingly on the horizon in Illinois. Individual caregiver fraud has also led to a movement to require background checks for caregivers.
Increasing regulation and legislation is a typical reaction to health care fraud, as regulators believe that they can solve all problems through another layer of rules. To the extent that there is a need for reforms, it is important to craft sound legislation that protects patients while putting the fewest restrictions on honest caregivers. Stakeholders should actively engage in the process of regulatory and legislative reform through the forums or state advocacy. Home care companies are encouraged to keep abreast of program integrity initiatives in their states, and to contact the National Council on Medicaid Home Care with any questions or concerns.