A Virginia man was sentenced on March 12, 2025, to nine years and three months in prison for healthcare and unemployment fraud schemes that resulted in nearly $1 million in losses. In addition to his term of imprisonment, he was ordered to pay $936,950.70 in restitution to Medicaid and $15,720 in restitution to the Virginia Unemployment Commission, and to forfeit $806,008.38.
According to court documents, from May 2015 through November 2023, the defendant targeted and defrauded two different government benefits programs: Virginia Medicaid’s consumer-directed care program and Virginia’s unemployment program.
The Virginia Medicaid Program provides medical assistance to indigent individuals who meet certain eligibility requirements. Under its consumer-directed care program, Medicaid authorizes the provision of personal and respite care services to eligible Medicaid recipients by a personal care attendant (PCA). Personal care services include a range of support services to enable Medicaid recipients to remain at or return home rather than enter a nursing facility. These services include assistance with activities of daily living, access to the community, self-administration of medication, other medical needs, supervision, and monitoring of health status and physical condition.
The defendant targeted Medicaid recipients to sign up for Medicaid-reimbursed personal care or respite care services. He and his co-conspirators designated numerous individuals as PCAs for those recipients. He used the personal identifying information (PII) of the Medicaid recipients and purported PCAs to create accounts for the submission of timesheets for purported personal care and respite care services.
For over eight years, the defendant submitted fraudulent timesheets to Medicaid showing thousands of hours of personal care and respite care services. He approved these timesheets, attesting that services were provided, when he and his co-conspirators knew that none of the PCAs provided any personal or respite care services to the Medicaid recipients.
In total, he and his co-conspirators knowingly caused Medicaid to pay at least $936,950.70 in fraudulent reimbursements for personal care and respite care services that never occurred.
The defendant also submitted fraudulent unemployment applications to the Virginia Employment Commission, resulting in $15,720 in unemployment benefits from Virginia’s unemployment insurance (UI) program and the Federal Pandemic Unemployment Compensation (FPUC) program. UI is a joint state-federal program intended to provide temporary financial assistance to unemployed workers under certain circumstances.
In 2020 and 2021, the defendant submitted four fraudulent unemployment applications using the PII of two of the purported PCAs from his Medicaid fraud scheme, falsely claiming that they had been terminated from their fake positions as PCAs. Two of these fraudulent applications were approved, one in the name of each of the two purported PCAs. He then submitted weekly certification requests for additional unemployment benefits for these applications, falsely representing that the purported applicants were still unemployed and in need of supplementary funds.
After his initial arrest in November 2023, the defendant repeatedly violated court orders prohibiting him from having contact with potential witnesses in the pending criminal case, including by contacting several individuals who have since been charged as co-conspirators.
Compliance Perspective
Issue
Medicaid service providers have a duty to bill honestly and accurately document the services for which they claim reimbursement. Falsifying signatures, incomplete documentation, and submitting false claims to Medicare or Medicaid are illegal. These actions, including failure to provide documented care or other deceptive practices, raise concerns about the quality of care and the integrity of the healthcare system. Falsified documentation and misuse of government funds contribute to fraud, waste, and abuse.
Discussion Points
- Review and update policies to ensure they address accurate documentation, the prevention of fraudulent billing, and compliance with Medicaid regulations. Policies should emphasize the accurate recording of service times and documentation standards.
- Provide thorough training to staff on the facility’s policies for care standards, documentation accuracy, and regulatory compliance. Ensure staff understand their responsibility to report fraud, waste, or abuse of government funds, with training upon hire and at least annually.
- Regularly audit medical records, timesheets, and billing documentation to ensure entries are accurate, complete, and timely. Audits should detect errors early and prevent the submission of false claims. Address any issues immediately, and ensure staff are aware of their role in identifying and reporting compliance concerns.
*This news alert has been prepared by Med-Net Concepts, Inc. for informational purposes only and is not intended to provide legal advice.*
