Vanessa Roberts Avery, United States Attorney for the District of Connecticut, announced on August 17, 2023, that a 55-year-old man of Johnstown, Pennsylvania, had waived his right to be indicted and pleaded guilty to one count of healthcare fraud and one count of violating the federal anti-kickback statute.
According to court documents and statements made in court, from 2017 to 2022, the defendant, a former resident of East Lyme, was a licensed professional counselor (LPC) with an office located in New London. In 2020, the Connecticut Medicaid program notified him that Medicaid was going to audit certain claims for psychotherapy services he had billed to Medicaid between March 2018 and February 2020. As part of its audit, Medicaid requested patient records for approximately 100 individual psychotherapy services that the defendant had billed to Medicaid.
In March 2021, Medicaid notified the defendant that the audit had determined that he had received over $225,000 in payments from Medicaid for services that he had not documented. Medicaid told him it would begin to collect the overpayment by deducting the overpayment in installments from future payments Medicaid would make to him.
Once the defendant learned the results of the audit and that he would have to pay the money back to Medicaid, he began submitting fraudulent claims to Medicaid for psychotherapy services that he never provided. All of the fraudulent claims he submitted to Medicaid represented that he had personally provided the nonexistent services.
As part of his plea, the defendant admitted that from March 1, 2020, to February 24, 2022, he submitted fraudulent claims to Medicaid totaling $695,048. In pleading guilty, he also admitted that he had engaged in a scheme to pay kickbacks to his Medicaid patients in order to induce them to receive psychotherapy services from him. He paid these kickbacks to patients in the form of cash payments, money orders, and Wal-Mart and VISA gift cards.
Sentencing is scheduled for November 8, at which time the defendant faces a maximum term of imprisonment of 20 years. He also has agreed to pay full restitution to Medicaid.
Compliance Perspective
Issue
Providers must ensure that the claims they submit to Medicare and Medicaid are true and accurate. One of the most important steps a provider can take is to have a robust internal audit program that monitors and reviews claims. If a provider identifies billing mistakes in the course of those audits, the provider must repay overpayments to Medicare and Medicaid within 60 days to avoid False Claims Act liability. Providers also can disclose billing errors to the OIG through the OIG Self-Disclosure Protocol.
Discussion Points
- Review your policies and procedures for preventing and reporting false claims and kickbacks and for conducting a Triple Check Process to verify accuracy of Medicare 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. Also train all staff on what can be considered a kickback. Provide training to appropriate staff on the Triple Check Process for ensuring accuracy of all Medicare Part A billing and supporting documentation before claims are submitted. Members of the compliance and ethics committee should periodically receive additional training on compliance and ethics issues in healthcare. 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 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.*
