A 54-year-old Pennsylvania man recently pleaded guilty in federal court to one count each of conspiracy to defraud the Pennsylvania Medicaid program and healthcare fraud.
During his plea hearing, the defendant admitted that between 2011 and 2017 he was an employee of one of four related entities operating in the home healthcare industry that were approved under the Pennsylvania Medicaid program to offer certain services to qualifying Medicaid recipients including Personal Assistance Services (PAS), service coordination, and non-medical transportation, among other services.
The defendant was the PAS Director and admitted to participating in a wide-ranging conspiracy to defraud the Pennsylvania Medicaid program to obtain millions of dollars in illegal Medicaid payments by submitting fraudulent claims for services that were never provided to the consumers identified on the claims, or for which there was insufficient or fabricated documentation to support the claims. As the PAS Director the defendant fabricated timesheets to reflect the provision of in-home PAS care that was never provided to the consumers identified on the timesheets. He caused the submission of Medicaid claims in the name of a “ghost” employee for PAS care that was never provided to the specified consumer. He admitted paying $160 for kickbacks every two weeks to a consumer in exchange for that person’s cooperation in the billing scheme. Total losses to the Pennsylvania Medicaid program attributed to the defendant were in excess of $100,000.
The conspiracy and healthcare fraud charges each carry a maximum total sentence of not more than 10 years in prison, a fine of $250,000, or both.
A total of sixteen defendants have been charged in connection with this investigation. The man is the ninth defendant to enter a guilty plea.
Compliance Perspective
Employing anyone who has been convicted of or who has pleaded guilty to participating in a scheme to submit fraudulent claims to Medicaid for reimbursement of services not provided or to have payed or received kickbacks for participation in a billing scheme may jeopardize a healthcare provider’s status as a Medicaid provider under state and federal regulations.
Discussion Points
- Review policies and procedures regarding the need to complete background checks and screenings of potential employees and outside healthcare providers for exclusion as a Medicare/Medicaid provider.
- Train staff on how to use the OIG online and downloadable databases to screen potential employees and outside healthcare providers for exclusion by Medicare and Medicaid.
- Periodically audit to ensure that potential employees and outside providers are being screened for exclusion by Medicare and Medicaid before being hired or providing services to residents, and that current employees and vendors/contractors are periodically rescreened. Communicate with residents and their families through the residents’ council the importance of ensuring that their Medicare/Medicaid statements reflect reimbursements for services that were actually provided.
FOR MORE INFORMATION ON THIS TOPIC: STAYING ON TOP OF EMPLOYEE CHECKS
