A Maryland man was sentenced to 18 months in prison for healthcare fraud. In addition, he was also ordered to pay $173,870,12 to the North Carolina Medicaid Fund as restitution.
According to court documents, the Maryland man was an officer and minority shareholder of an out-of-state company that entered into an agreement with a North Carolina dentist. Per the agreement, the out-of-state company would provide professional management services to the dentist, including submitting Medicaid claims, and the dentist would provide dental services to patients living in skilled nursing facilities throughout North Carolina.
Beginning September 2015 through April 2017, the man and others knowingly submitted fraudulent dental claims to Medicaid. Court documents show that although the dental records showed that only approximately 107 prophylaxes and 24 debridements had been performed for Medicaid recipients living at a skilled nursing facility, false claims were submitted representing that 771 prophylaxes and 611 debridements were performed for these recipients.
In total, the healthcare fraud resulted in Medicaid paying approximately $173,870.12 for services that had not been rendered. The funds were deposited into an account to which the Maryland man had access. The checks written to the man, to ‘cash’, and to the out-of-state company totaled approximately $177, 034.
The Medicaid Investigations Division investigates and prosecutes healthcare providers that defraud the Medicaid program, patient abuse of Medicaid recipients, patient abuse of any patient in facilities that receive Medicaid funding, and misappropriation of any patient’s private funds in nursing homes that receive Medicaid funding.
Compliance Perspective
Issue
It is essential that all agreements are reviewed carefully before signing. Legal counsel should be contacted for review as necessary. In addition, any facility receiving federal or state funding should ensure that all claims that are submitted are accurate, and the services were necessary and well documented.
Discussion Points
- Review signed agreements to ensure that they comply with legal requirements, and that there are no discrepancies in the agreement and claims that are filed.
- Train appropriate employees to review all claims submitted to ensure accuracy and that services were actually performed and well documented.
- Periodically audit claims that are being submitted to ensure that they are accurate and well supported by documentation.
FOR MORE INFORMATION ON THIS TOPIC view: FRAUD MODULE 10 – VENDOR CONTRACTS.
