Home Care Medicaid Fraud Developments in Florida, Massachusetts, and Illinois
April 7, 2014 03:40 PM
The National Council on Medicaid Home Care – a NAHC affiliate - reports on recent developments in home care Medicaid fraud and abuse, including: 1) alleged caregiver fraud in Florida; 2) alleged and convicted personal care services fraud in Massachusetts; and 3) convicted personal care services fraud in Illinois.
As reported by the Florida Attorney General’s office, on April 1, Julia Privis and Alla Privis were arrested for allegedly billing over $18,000 of Medicaid services not rendered. The services included bathing and skin care, range of motion exercises, and urine tests. The Privises were employees of Ultimate Home Care, Inc.—one was a home health agency administrator and the other was a home health aide.
Julia Privis has been charged with Medicaid Fraud (one count, second-degree felony), and Grand Theft (two counts, third-degree felonies). Her maximum sentence if convicted is 25 years in prison. Alla Privis has been charged with Medicaid fraud (one count, third-degree felony), and Grand Theft (one count, third-degree felony). She faces a maximum prison sentence of 10 years.
To see the press release, click here.
Also as reported by the Florida Attorney General’s office, on March 27, Melinda Warren surrendered to authorities for billing over $25,000 in unauthorized services to Florida’s Agency for Persons with Disabilities (APD) Consumer Direct Care Plus program. Warren knowingly hired someone unauthorized to provide these services, and then billed the program as if she had provided the services herself.
Warren is charged with Grand Theft, Medicaid Fraud, and Employing a Provider without a Background Screening. Warren faces a 30 year prison sentence as well as over $120,000 in fines if convicted.
To see the press release, click here.
As reported by the Massachusetts Attorney General’s office, on March 31, James Lynch pled guilty to fraudulently billing approximately $63,000 to Medicaid for services not rendered. As a personal care attendant, Lynch billed Medicaid for services conducted while he was working at another job. Allegedly, the beneficiary worked with Lynch to inflate his timesheets; in return, the beneficiary allegedly received half of these paid claims.
Holly-Beth Ropel, who was indicted with Lynch on the same charges, is scheduled for a pre-trial conference on April 17. These two defendants were two of out of 32 indicted personal care attendants and surrogates resulting from investigations from the Massachusetts Attorney General’s office in February 2013. For details of the indictments and later arraignments, click hereand here.
To see the March 31 press release, click here.
As reported by the Worcester Telegram & Gazette, on March 20, Beverly Cousin and her son Rashad Cousin were indicted for allegedly fraudulent billing over $96,000 in personal care attendant services. Beverly Cousin was charged with making false Medicaid claims (5 counts) and larceny of more than $250 by false pretenses (5 counts). Rashad Cousin was charged with three counts of each of the same charges. Ms. Cousin, a personal care attendant services beneficiary, allegedly falsified time sheets that reflected services provided by Rashad while he was living outside of Massachusetts. Ms. Cousin also allegedly submitted timesheets for another son, who was in prison at the time, and other timesheets for when she was hospitalized.
To see the news article, click here.
As reported by the United States Attorney’s Office for the Southern District of Illinois, on March 20, Tisa Vaughn, was found guilty of engaging in a scheme to commit health care fraud. Specifically, she billed Illinois’ Home Services Program for personal assistant services not rendered. These services were billed as provided to her sister while her sister was at the hospital, or when Ms. Vaughn was otherwise not caring for her sister.
Sentencing is scheduled for July 11. Ms. Vaughn faces a maximum sentence of 10 years in prison, 3 years supervised release, and a $250,000 fine.
To see the press release, click here. To see Ms. Vaughn’s July 2013 indictment, click here.
Stephen R. Wigginton, United States Attorney for the Southern District of Illinois, stated: “Nationwide, the biggest fraud problem in the Medicaid program has been these personal assistant programs which represent the number one fraud complaint to state Medicaid fraud units.” It appears that the concerns with billing for services never rendered are especially acute in consumer-directed care programs, as is the case in the Illinois and Massachusetts personal care programs, and Florida’s Consumer Direct Care Plus program, above. As Wigginton further stated:
Especially vulnerable to fraud are programs, such as the one implemented in Illinois, that allows the Medicaid recipient to control the selection and payment of personal care attendants. In most cases, the personal care assistant is a relative or family friend, who often is a ghost employee. In a typical fraud scenario, the scam payments made by the State of Illinois are split between the Medicaid recipient and the ghost employee. [Illinois press release].
While consumer-directed care programs 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.
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.
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 Council with any questions or concerns.