Articles Tagged with Medicaid Fraud

SUMMER MATHESON and TERRENCE EWING, co-owners of Laynie Foundation Inc., and foundation employee RICHARD GRUNDY, have been indicted for fraudulently billed Illinois Medicaid for mental health services not provided.  Matheson, Ewing and Grundy also used the Matteson-based foundation to seek payment from Illinois Medicaid for non-reimbursable activities, such as internal case reviews, staff training, clinical supervision and recordkeeping, the indictment alleges.  The indictment also accuses Matheson of attempting to cover up the fraud by directing foundation personnel to backdate and falsify patient records to make it appear that a licensed practitioner had reviewed and approved certain mental health services, when, in fact, Matheson knew that a practitioner had not reviewed and approved those services.  As a result of the fraud, Matheson, Ewing and Grundy fraudulently obtained approximately $4 million from Illinois Medicaid and managed-care organizations used by Illinois Medicaid, the indictment states.

The indictment charges Matheson, 41, and Ewing, 57, both of Dyer, Ind., with six counts of health care fraud.  Matheson is also charged with one count of obstruction of justice.  Grundy, 34, of Chicago, is charged with five counts of health care fraud.

The indictment was announced by John R. Lausch, Jr., United States Attorney for the Northern District of Illinois; Lamont Pugh III, Special Agent-in-Charge of the Chicago Region of the U.S. Department of Health and Human Services Office of Inspector General; and Jeffrey S. Sallet, Special Agent-in-Charge of the Chicago office of the FBI.  The Illinois Attorney General’s Office and Illinois State Police assisted in the investigation.  The government is represented by Assistant U.S. Attorneys Prashant Kolluri and Charles W. Mulaney.

IMG_0366-300x200Dr. Antonio Reyes-Vizcarrondo was indicted for one count of conspiracy to commit health care fraud and one count of health care fraud following allegations that he submitted false claims to both Medicare and Medicaid.

According to the Department of Justice, Reyes-Vizcarrondo submitted a total of 8,159 claims between 2008 and 2015, resulting in profits of nearly $900,000. Out of these funds, Medicare and Medicaid was defrauded for almost $602,000 with the remaining funds having been paid out by other health care organizations.

As part of his health care fraud scheme, Reyes-Vizcarrondo would submit claims for services performed by other physicians, and then conceal the profits by diverting them to his personal accounts.

IMG_0257-300x180Crispin Abarientos, M.D., of Middletown, Connecticut, pleaded guilty to one count of health care fraud in Hartford federal court. According to court statements, Abarientos was a physician that operated out of Middlesex Rheumatology and submitted false claims to Medicaid regarding the use of the drug Remicade on behalf of his patients.

Remicade is primarily used to treat rheumatoid arthritis, and is a drug that was commonly prescribed to Middlesex Rheumatology patients. When Medicaid patients are treated with Remicade the prescribing physician is required to submit claims to their local Medicaid facility, in this case Connecticut Medicaid, on their behalf. Medicaid then pays a partnered pharmacy for the requested drugs, which are then delivered to the prescribing doctor’s facility.

While this was a procedure that Abarientos regularly followed for many of his patients, he admitted to submitting claims to Medicaid for large quantities of the drug that were never intended to be distributed to his patients. He would then submit claims to insurers for reimbursement of the drugs, profiting from the scheme without any out-of-pocket expenses. In total, Abarientos was able to obtain around $895,000 worth of Remicade, which were never distributed to his patients for treatment.

IMG_0209-300x200A whistleblower in Oklahoma, Jennifferr Baird, filed a complaint against the hospital she worked at as a registered nurse for fraudulent Medicaid billing practices. Following the filing, Oklahoma Heart Hospital agreed to settle the allegations with a $2.8 million fee.

Baird was in charge of a team of seven staff members and alleged that for at least seven years the hospital consistently billed Medicaid at inpatient rates, even if the patient was being treated as an outpatient.

“First, OHH routes almost all of its Medicaid patients to inpatient treatment, when many should be classified as outpatient; in doing so OHH is able to charge significantly larger fees for the same treatment. The fraud is evidenced by the fact that OHH does not treat its Medicare or privately insured patients similarly.”, the lawsuit stated.

NC-health-care-fraud-300x199Mental health company owner, Catinia Denise Farrington of Cyprus, Texas, pleaded guilty to health care fraud and tax evasion in September of 2018. As of March 1st, 2019, she has been sentenced to 60 months in prison after profiting $4 million from Medicaid and just under $400,000 from her tax evasion scheme.

Health Care Fraud Conspiracy

According to prosecutors, Farrington owned a mental health care company out of North Carolina, Durham County Mental Health and Behavioral Health Services, LLC. Through this company, she submitted thousands of fraudulent claims to Medicaid for services that were never performed. These incidents occurred between 2011 and 2015, but this is not the only fraudulent activity that Farrington participated in during this time.

 A New York-based  pediatrics practice Freed, Kleinberg, Nussbaum, Festa & Kronberg M.D., LLP (Practice), as well as various current and former partner physicians of the Practice, including Arnold W. Scherz, M.D., Mitchell Kleinberg, M.D., Michael Nussbaum, M.D., Robert Festa, M.D., and Jason Kronberg, D.O. (Partners) have agreed to pay $750,000 to settle allegations of Medicaid fraud. The agreement settles allegations that the Practice and Partners did not routinely enroll all of their employee providers treating Medicaid patients in the Medicaid program, and instead used the Partners’ Medicaid provider identification numbers to bill for the treatment of Medicaid beneficiaries by unenrolled employee providers. An investigation conducted by the Attorney General’s office found that the false claims occurred at many of the practice’s Long Island locations. The pediatrics practice has locations in Holbrook, Port Jefferson, Shirley, and Wading River, NY. New York’s Medicaid program will receive $450,000 as part of the $750,000 settlement agreement.

“Providers who are not properly enrolled in Medicaid before treating Medicaid beneficiaries undermine the integrity of the program and its efforts to serve our neediest New Yorkers,” said Attorney General Schneiderman. “Those serving Medicaid beneficiaries must be properly credentialed and thoroughly vetted prior to Medicaid enrollment to ensure that beneficiaries get the care they deserve from qualified professionals.”

Specifically, the settlement agreement resolves allegations that, from July 1, 2004 through December 31, 2010, the Practice and Partners did not enroll all of their provider employees in Medicaid prior to allowing them to treat patients who were Medicaid beneficiaries. Instead, providers employed by the Practice would treat Medicaid patients and bill under the Partners’ Medicaid identification numbers, as if the billing Partners were the ones seeing those patients, even when they had not.

Medicare fraudFighting Medicaid Fraud

Hearing the term Medicaid fraud may conjure up images of lawyers and government officials, but the true cost is actually much closer to home for many people. Fraud and abuse in Medicaid cost taxpayers billions of dollars every year. Funds intended to help the sick end up being wasted.

But worse than the wasted time is the risk to patients caught up in unnecessary procedures that just line the pockets of unscrupulous health care companies. Imagine if you found out that your child had an unnecessary surgery just so that agency could make a few hundred dollars.

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Dental management company Benevis LLC (formerly known as NCDR LLC) and more than 130 of its affiliated Kool Smiles dental clinics for which Benevis provides business management and administrative services, will pay the United States and participating states a total of $23.9 million, plus interest, to resolve allegations that they knowingly submitted false claims for payment to state Medicaid programs for medically unnecessary dental services performed on children insured by Medicaid.

 The United States alleged that between January 2009 and December 2011, Benevis and Kool Smiles clinics located throughout 17 states knowingly submitted false claims to state Medicaid programs for medically unnecessary pulpotomies (baby root canals), tooth extractions, and stainless steel crowns, in addition to seeking payment for pulpotomies that were never performed.  The United States alleges that Kool Smiles clinics routinely pressured and incentivized dentists to meet production goals through a system that disciplined “unproductive” dentists and awarded “productive” dentists with substantial cash bonuses based on the revenue generated by the procedures they performed.  According to the government’s allegations, Kool Smiles clinics ignored complaints from their own dentists regarding overutilization.  In addition, the United States further alleged that Kool Smiles clinics located in Texas knowingly submitted false claims to the Texas Medicaid Program for First Dental Home (FDH), a program intended to provide a comprehensive package of dental services aimed at improving the oral health of children under three years of age.  These clinics are alleged to have submitted false claims for FDH services that were not fully provided.

Of the $23.9 million to be paid by Benevis and its affiliated Kool Smiles clinics, the federal government will receive a total of $14,244,073.49, plus interest, and a total of $9,655,926.51, plus interest, will be returned to individual states, which jointly funded improper claims submitted to state Medicaid programs.

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Pharmaceutical company Mylan will pay a total of $20.3 million to the Massachusetts Medicaid program (MassHealth) to resolve allegations that it knowingly underpaid rebates owed to the Medicaid program for EpiPens dispensed to MassHealth members, Attorney General Maura Healey announced today.

The payment is part of a global settlement with the United States, the District of Columbia, and all 49 other states settling allegations against Mylan Inc. and its wholly-owned subsidiary, Mylan Specialty L.P. (Mylan).

“Mylan knowingly misrepresented this drug to MassHealth in order to underpay on rebates and make a profit at the expense of our state,” said AG Healey. “This settlement brings critical funds back to our MassHealth program. Companies that receive payments from taxpayer-funded programs must be held accountable when they abuse this system.”

Sue Thayer, a former Planned Parenthood Heartland Clinic Manager has filed a whistleblower lawsuit under The False Claims Act, alleging that the company filed nearly 500,000 false claims with Medicaid, from which PP received and retained over $28 million. In the suit, Thayer says that Planned Parenthood implemented the “C-Mail” program which automatically mailed a year’s supply of birth control pills to women who had only been seen once at the PP clinic. Those women were usually seen by personnel who were not qualified health care professional the suit alleges. Planned Parenthood’s cost for a 28 day supply of birth control pills mailed to clients was $2.98 but the Medicaid reimbursement received was $26.32. It is also alleged that when the postal service returned the pulls, PP would resell the same birth control pills and bill Medicaid again instead of crediting Medicaid or destroying the pills. The lawsuit, Thayer v. Planned Parenthood of the Heartland is pending in the District Coourt for the Southern District of Iowa. Jeffrey Newman represents whistleblowers. email; Jeff@JeffNewmanLaw.com