A 56-year-old man of Johnstown, Pennsylvania, was sentenced on July 9, 2024, to three years of probation, the first 12 months of which he must serve in home confinement under electronic monitoring, for healthcare fraud and kickback offenses. He was also ordered to pay restitution of $695,048 to Medicaid.
According to court documents and statements made in court, from 2017 to 2022, the defendant, a former resident of East Lyme, Connecticut, was a licensed professional counselor (LPC) with an office located in New London. In 2020, the Connecticut Medicaid program notified the defendant that they were going to audit certain claims for psychotherapy services that he had billed to them between March 2018 and February 2020. As part of its audit, Medicaid requested patient records for approximately 100 individual psychotherapy services he had billed to them.
In March 2021, Medicaid informed the defendant that they had identified over $225,000 in payments made for undocumented services. They notified him that they would recoup this overpayment through deductions from future payments. Upon learning of the audit results and the repayment requirement, the defendant started submitting fraudulent claims to Medicaid for psychotherapy services he never rendered, falsely asserting that he had provided these services himself.
The defendant also 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.
Compliance Perspective
Issue
Medicaid service providers, in addition to a basic duty to bill honestly, are required to reliably document the services for which they claim reimbursement, and to promptly make those records available to State investigators. Under federal and state anti-kickback statutes, you may not knowingly and willfully offer, pay, solicit, or receive anything of value to induce or reward for referrals of federal or state healthcare program business. The prohibition against kickbacks applies to those who pay for referrals and to those who receive them. Kickbacks can take various forms, such as bribes or rebates. They can be given in cash or in kind. Failure to promptly report a kickback can result in lawsuits, fines, and other sanctions.
Discussion Points
- Review your policies and procedures for preventing and reporting false claims and kickbacks. 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 to ensure accuracy of all 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.
*This news alert has been prepared by Med-Net Concepts, LLC for informational purposes only and is not intended to provide legal advice.*
