Vanessa Roberts Avery, United States Attorney for the District of Connecticut, announced on June 26, 2023, that a counselor was sentenced to 30 months of imprisonment, followed by three years of supervised release, for healthcare fraud. According to court documents and statements made in court, the 50-year-old man provided counseling services to individual patients, including those with mental health and trauma issues. He was enrolled individually as a Behavioral Health Clinician provider in the Connecticut Medicaid Program.
Between January 2018 and July 2022, the counselor submitted and caused to be submitted fraudulent claims to Medicaid for counseling services that were purportedly provided to Medicaid clients. Specifically, he submitted claims for dates of service when no services of any kind had been provided to the Medicaid clients identified in the claims.
In October 2020, the Connecticut Department of Social Services (DSS) audited the counselor and requested documentation from him for six sample clients. In response, he made multiple false statements for the purpose of delaying the progress of DSS’s audit and to conceal his offense. For example, in February 2021, he sent an email to DSS in which he falsely represented that one of the files DSS requested was destroyed by a water leak above his office when, in fact, no such water leak had occurred.
Through this scheme, the counselor defrauded Medicaid of $1,044,387.08. He was ordered to pay full restitution.
Compliance Perspective
Issue
It is illegal to submit claims for payment to Medicare or Medicaid that you know or should know are false or fraudulent. Filing false claims may result in fines of up to three times the programs’ loss plus $11,000 per claim filed. Under the civil False Claims Act, each instance of an item or a service billed to Medicare or Medicaid counts as a claim, so fines can add up quickly. Facility staff should be knowledgeable in how to report suspicious billing practices. A nonretaliatory environment for reporting suspicious billing practices is mandatory for all facilities.
Discussion Points
- Review your policies and procedures for preventing and reporting a false claim and for conducting a Triple Check Process to verify accuracy of Medicare and Medicaid claims. Ensure that your policies are reviewed at least annually and updated when new information becomes available.
- Train all staff upon hire and at least annually on your compliance and ethics policies and procedures and on what can be considered a false claim. Provide training to appropriate staff on the Triple Check Process for ensuring accuracy of all Medicare and Medicaid billing and supporting documentation before claims are submitted. Document that these trainings occurred and file the signed document in each employee’s education file.
- Periodically perform audits to ensure all staff are aware of compliance and ethics concerns and understand their responsibility to report any potential compliance and ethics violations to their supervisor, the compliance and ethics officer, or via the anonymous hotline. Audit to ensure that the Triple Check Process is being followed each month before claims are submitted to Medicare and Medicaid, and that any identified irregularities are corrected.
*This news alert has been prepared by Med-Net Concepts, LLC for informational purposes only and is not intended to provide legal advice.*
