States Medicaid & Other Health Care Fraud Enforcement Successes Continue

Amid all the heavy media coverage on the role of the Federal Health Care Fraud Prevention & Enforcement Action Team (HEAT) and other federal officials in high-profile health care fraud enforcement actions the arrest last week of Dallas area physician Jacques Roy and others for their alleged involvement in a $375 million home health care fraud scheme, the growing role and success of the Medicaid and other health care fraud enforcement efforts by state attorney generals and other state authorities often to goes relatively unreported and largely unnoticed.

Often receiving much less media attention, the record makes clear that states also are key players in the war against health care fraud.   The indictments and convictions resulting from these state Medicaid and other health care fraud task forces target both providers and beneficiaries. For instance:

  • On March 2, 2012; Oklahoma Attorney General Scott Pruitt charged a father and son with Medicaid fraud.
  • On February 29, 2012, the Pennsylvania Attorney General announced the arrest of a former Bradford County social worker on charges of using eight different schemes to defraud Medical Assistance and private insurance companies out of more than $100,000.
  • On February 29, 2012, Florida Attorney General Pam Bondi announced the arrest of a home health aid Clifford Edouard on charges with defrauding the Florida Medicaid program out of more than $35,000.
  • On February 28, 2012, New York Attorney General A.G. Scheiderman announced his office had obtained Medicaid fraud settlements totaling $28 from Dava Pharmaceuticals, Inc. and KV Pharmaceutical Company.   Dava was charged with misclassifying drugs to evade paying its obligations to Medicaid, while KV was charged with improperly billing government programs for  two unapproved drugs did not qualify for coverage under federal and state health care programs.
  • On February 24, 2012, Maryland Attorney General Douglas F. Gansler announced that nurse Hellen Njeri Ngatia, 43, and her daughter pled guilty to improperly billing Medicaid for providing nursing services for a seriously ill 16-month-old infant when the child was in fact cared was provided by her unlicensed daughter.
  • On February 24, 2012,  New Hampshire Attorney General Michael A. Delaney secured an indictment against Tracy Eiserman on charges of theft by deception for allegedly stealing more than $4,300 from MAS Home Care (“MAS”), a provider of home health aide services to disabled adults.
  • On February 23, 2012, a Seattle woman was sentenced for Medicaid fraud after she plead guilty to First Degree Theft and filing a Medicaid False Statement stemming from home care services provided to her brother.
  • On February 21, 2012; the Kansas Attorney General secured Medicaid fraud and forgery convictions against a Junction City woman.
  • On February 17, 2012, an Oklahoma court sentenced an Enid couple that plead guilty to Medicaid Fraud charges brought by Oklahoma Attorney General Scott Pruitt.
  • On February 16, 2012, New York Attorney General Eric T. Schneiderman announced that Suzanne Benizio, the alleged ringleader of an illegal prescription drug operation charged with forging more than 250 prescriptions for narcotics, like OxyContin and Roxicodone was sentenced to two consecutive sentences totaling four to eight years in state prison and ordered to repay the New York State Medicaid program over $200,000 after pleading guilty to Forgery.
  • On February 14, 2012, Oklahoma Attorney General Scott Pruitt announced that an Oklahoma counseling agency owner, director and therapist were sentenced to a 10-year deferred sentence and ordered to pay $14,012 in restitution for Medicaid fraud. 
  • On February 14, 2012,  Louisiana Attorney General Buddy Caldwell announced his Medicaid Fraud Control Unit secured grand jury indictments  against the owner of a personal care attendant business for participating in a conspiracy to forge CPR and First Aid training certification documents for his employees. The same day, Attorney General Caldwell also announced grand jury indictments against the owners of a Hammond personal care business and their family members for their role in operating a criminal enterprise designed to siphon dollars from the Louisiana Medicaid Program.
  • On February 9, 2012, a DeKalb County Jury found Janine Wright, a speech therapist from Stone Mountain, guilty of defrauding the Georgia Medicaid program on charges brought by that the Georgia Attorney General’s office.
  • On February 7, 2012, Louisiana Attorney General Buddy Caldwell announced his office has recovered $25.2 million from five pharmaceutical companies that he sued alleging unlawful inflation of drug costs paid by Louisiana taxpayers through the Medicaid program.
  • On February 1, 2012,  DeAngelo Henderson was sentenced  to 12 to 48 months in prison and ordered to repay $336,000 in restitution, penalties, and costs in a Medicaid fraud case involving Golden Heart Medical Supply brought b y Nevada Attorney General Catherine Cortez Masto.
  • On February 2, 2012, New Jersey  Jeffrey S. Chiesa announced that the owner of a now-defunct Newark mental health and substance abuse counseling center was convicted of defrauding Medicaid.

To learn more details about these and other state health care fraud actions, see here.

Prompted by the need to managing burgeoning state health care program budgets and the conditions of participation in Medicaid and other programs receiving federal funds to administer fraud detection and enforcement efforts,
these and a growing list of other state initiated or involved health care fraud convictions reflect the growing emphasis and effectiveness of State attorneys general and other state officials on detecting and prosecuting Medicaid and other health care fraud.

Health Care Providers Must Act To Manage Risks

The continuing success of these and other federal health care fraud investigation and enforcement efforts are adding new pressure on health care providers and others to strengthen their compliance practices and documentation to avoid getting caught in the ever tightening health care fraud dragnet.  When designing and administering these efforts, health care providers and others need to take into account and be prepared to survive scrutiny from federal or state officials alone, or increasingly acting as a well-coordinated team.

In response to the growing emphasis and effectiveness of Federal and state officials in investigating and taking action against health care providers and organizations, health care providers covered by federal false claims, referral, kickback and other health care fraud laws should consider auditing the adequacy of existing practices, tightening training, oversight and controls on billing and other regulated conduct, reaffirming their commitment to compliance to workforce members and constituents and taking other appropriate steps to help prevent, detect and timely redress health care fraud exposures within their organization and to position their organization to respond and defend against potential investigations or charges.

For More Information Or Assistance

If you need help reviewing or responding to these or other health care related risk management, compliance, enforcement or management concerns, the author of this update, attorney Cynthia Marcotte Stamer, may be able to help. Vice President of the North Texas Health Care Compliance Professionals Association, Past Chair of the ABA Health Law Section Managed Care & Insurance Section and the former Board Compliance Chair of the National Kidney Foundation of North Texas, Ms. Stamer has more than 24 years experience advising health industry clients about these and other matters. Her experience includes advising hospitals, nursing home, home health, rehabilitation and other health care providers and health industry clients to establish and administer compliance and risk management policies; prevent, conduct and investigate, and respond to peer review and other quality concerns; and to respond to Board of Medicine, Department of Aging & Disability, Drug Enforcement Agency, OCR Privacy and Civil Rights, HHS, DOD and other health care industry investigation, enforcement and other compliance, public policy, regulatory, staffing, and other operations and risk management concerns.

A popular lecturer and widely published author on health industry concerns, Ms. Stamer continuously advises health industry clients about compliance and internal controls, workforce and medical staff performance, quality, governance, reimbursement, and other risk management and operational matters. Ms. Stamer also publishes and speaks extensively on health and managed care industry regulatory, staffing and human resources, compensation and benefits, technology, public policy, reimbursement and other operations and risk management concerns. Her insights on these and other related matters appear in the Health Care Compliance Association, Atlantic Information Service, Bureau of National Affairs, The Wall Street Journal, Business Insurance, the Dallas Morning News, Modern Health Care, Managed Healthcare, Health Leaders, and a many other national and local publications.  You can get more information about her health industry experience here. If you need assistance responding to concerns about the matters discussed in this publication or other health care concerns, wish to obtain information about arranging for training or presentations by Ms. Stamer, wish to suggest a topic for a future program or update, or wish to request other information or materials, please contact Ms. Stamer via telephone at (214) 452-8297 or via e-mail here.

If you or someone else you know would like to receive future updates about developments on these and other concerns from Ms. Stamer, see here.

About Solutions Law Press

Solutions Law Press™ provides business risk management, legal compliance, management effectiveness and other resources, training and education on human resources, employee benefits, compensation, data security and privacy, health care, insurance, and other key compliance, risk management, internal controls and other key operational concerns. If you find this of interest, you also be interested reviewing some of our other Solutions Law Press resources including:

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THE FOLLOWING DISCLAIMER IS INCLUDED TO COMPLY WITH AND IN RESPONSE TO U.S. TREASURY DEPARTMENT CIRCULAR 230 REGULATIONS.  ANY STATEMENTS CONTAINED HEREIN ARE NOT INTENDED OR WRITTEN BY THE WRITER TO BE USED, AND NOTHING CONTAINED HEREIN CAN BE USED BY YOU OR ANY OTHER PERSON, FOR THE PURPOSE OF (1) AVOIDING PENALTIES THAT MAY BE IMPOSED UNDER FEDERAL TAX LAW, OR (2) PROMOTING, MARKETING OR RECOMMENDING TO ANOTHER PARTY ANY TAX-RELATED TRANSACTION OR MATTER ADDRESSED HEREIN.

©2012 Cynthia Marcotte Stamer, P.C. Non-exclusive license to republish granted to Solutions Law Press.  All other rights reserved.

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