A 52-year-old woman pleaded guilty to conspiring to defraud North Carolina Medicaid in a scheme that resulted in more than $400,000 in fraudulent billing, the US Attorney’s Office, Eastern District of North Carolina, announced on January 26, 2024. She now faces up to 10 years in prison and a potential fine.
According to the filed charge and information summarized in court, the defendant was a social worker in New Hanover County who conspired with a licensed mental health counselor to defraud Medicaid. She used her government employment to obtain personally identifying information (PII) of New Hanover County residents enrolled in Medicaid, including their Medicaid ID numbers. In exchange for an agreed-upon fee per beneficiary, she then provided the PII to the counselor, knowing it would be used to generate fraudulent claims for services never rendered.
For example, the counselor fraudulently billed Medicaid for over 24 one-hour mental health appointments in a single day; and billed Medicaid for in-person services rendered in disparate locations in Eastern North Carolina within close temporal proximity. In another instance, she submitted claims for services rendered to an unborn beneficiary still in utero at the time of the purported service being rendered. Investigators have attributed over $400,000 of the counselor’s fraudulent Medicaid billing to the beneficiary PII the social worker provided to the counselor. Late last year, the counselor pleaded guilty and is awaiting sentencing.
The US Department of Health and Human Services, Office of the Inspector General, is leading the investigation with the assistance of the North Carolina Medicaid Investigations Division.
Compliance Perspective
Issue
It is the obligation of each nursing facility to protect residents from financial abuse and exploitation by taking the required precautions in keeping residents’ PII as confidential as possible. Also, 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 on protecting residents’ PII and preventing financial abuse and exploitation. Also review your policies and procedures for preventing and reporting a false claim. Update your policies if needed.
- Train staff who have access to residents’ PII on your policies for protecting the information. Also train staff on what can be considered a false claim. Include information on how to report concerns and suspected violations, and make sure staff know that prompt reporting is mandatory. Document that the trainings occurred and file the signed documents in each employee’s education file.
- Periodically audit to ensure that staff who have access to residents’ personal information are aware of the proper procedures to follow to prevent PII exposure. Also periodically perform audits to ensure staff are aware of their responsibility to identify and report compliance and ethics concerns, and understand that it is their responsibility to report violations to their supervisor, the compliance 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.*
