The Vermont Attorney General’s Office announced on June 3, 2024, that it had filed civil enforcement actions against two Vermont Medicaid providers for fraud. The lawsuits, currently pending in Vermont Superior Court, Chittenden Unit, Civil Division, were investigated and brought by the Attorney General’s Medicaid Fraud and Residential Abuse Unit (MFRAU) and allege separate violations of the Vermont False Claims Act.
In the first case, a psychotherapist (Defendant 1) of Cotuit, Massachusetts, and his business associate (Defendant 2), of New York, New York, are accused of conspiring to “upcode,” or unlawfully increase Vermont Medicaid reimbursement by billing with inaccurate information. Defendant 1 is alleged to have allowed Defendant 2, who is not licensed to practice medicine or psychotherapy, to provide “talk therapy” to Vermont Medicaid patients. Defendant 1 then billed Defendant 2’s time to Vermont Medicaid at a licensed clinical psychotherapist’s full rate, resulting in significant overpayments to Defendant 1’s practice.
Additionally, MFRAU’s investigation found evidence that Defendant 1 routinely billed Vermont Medicaid for “impossible time,” whereby he claimed to have personally provided more than 24 hours of Medicaid service on a single date. The defendants are further alleged to have obscured their actions by not maintaining or providing Medicaid treatment records necessary to verify that appropriate services had been rendered.
In another case, a mental health counselor from Rutland, Vermont, faces allegations of Medicaid fraud. Despite being the subject of numerous public complaints about the quality of care, she declined to furnish Vermont Medicaid treatment records to state authorities and her own patients, as mandated by law and professional ethics.
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. Failure to do so exposes providers to potential liability under state and federal laws. Violation of the False Claims Act can result in a judgment of three times the amount of public funds defrauded, plus penalties for every false claim made to the State. Under the civil False Claims Act, each instance of an item or a service billed to Medicaid or Medicare 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. 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 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.*
