A Missouri woman was indicted on four counts of healthcare fraud by a federal grand jury on October 30, 2024, accused of defrauding Missouri Medicaid out of more than $3 million over the course of more than a decade.
According to the indictment, the defendant owned a home healthcare company but concealed her ownership from state officials due to a 2012 criminal conviction. Instead, she falsely submitted paperwork claiming that someone else owned the company. Additionally, she allegedly submitted or caused to be submitted fraudulent claims to Missouri Medicaid seeking reimbursement for home healthcare services that were never provided. In some instances, the care recipients were in the hospital and could not have received home healthcare. On numerous other occasions, she submitted claims when the company did not have any timesheet records or any documentation to support the services, because those services were never provided.
Each fraud charge carries a potential penalty of up to 10 years in prison, a $250,000 fine, or both prison time and a fine.
“The alleged fraudulent enrollment and submission of false claims by this business owner to Medicaid undermines the integrity of the program and diverts essential resources from those who genuinely need assistance,” said Linda T. Hanley, Special Agent in Charge with the US Department of Health and Human Services Office of Inspector General (HHS-OIG). “HHS-OIG will continue collaborating with the Missouri Medicaid Fraud Control Unit to combat home healthcare fraud in Medicaid, ensuring the program remains sustainable for those who truly depend on it.”
Compliance Perspective
Issue
Professional licenses should be verified upon hire, and the Office of Inspector General’s (OIG) List of Excluded Individuals and Entities (LEIE) should be checked monthly to ensure no current employees are listed. Professional license active status should also be tracked regularly. Anyone who hires or partners with an individual or entity on the LEIE may be subject to civil monetary penalties (CMP). Misuse of allocated public funds can be seen as fraud, waste, and abuse of government funds. It is illegal to submit claims for payment to Medicare or Medicaid that you know or should know are false or fraudulent. 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 and update policies and procedures to verify the status of professional licenses at the time of hire, including ensuring that the individual is not listed on a state or OIG exclusion list. Ensure compliance with Medicaid regulations by regularly reviewing internal processes for documenting services and verifying the accuracy of documentation, including proper completion of assessments by licensed professionals and accurate recording of service times.
- Train staff to follow established protocols for verifying the licenses and certifications of employees both at the time of hire and on an ongoing basis. Emphasize the importance of maintaining up-to-date credentials and the obligation of licensed professionals to notify administration of any changes in their license status. Provide training to appropriate staff on Medicaid billing procedures to ensure billing practices and supporting documentation are accurate and comply with all regulatory standards before claims are submitted.
- Periodically audit to verify that the licensing and certifications of employees are valid and up to date and that OIG LEIE checks are routinely conducted. Regularly conduct audits of documentation and billing to prevent and detect errors before they progress to a false claim. Immediately address any negative findings. Also periodically perform audits to ensure all staff are aware of the importance of identifying compliance and ethics concerns and their responsibility to report them to their supervisor, the compliance and ethics officer, or via the anonymous hotline.
*This news alert has been prepared by Med-Net Concepts, Inc. for informational purposes only and is not intended to provide legal advice.*
