A 52-year-old woman was sentenced to 14 months in federal prison followed by three years of supervised release for conspiring to defraud North Carolina Medicaid of more than $400,000. She was also ordered to pay $400,000 in restitution.
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, the social worker then provided the PII to the counselor, knowing it would be used to generate fraudulent claims for services never rendered. Investigators have attributed over $400,000 of the counselor’s fraudulent Medicaid billing to the beneficiary PII the social worker had provided to her. The counselor pleaded guilty late last year and is awaiting sentencing.
“HHS-OIG, along with our law enforcement partners, is committed to holding individuals responsible for failing to safeguard confidential patient information,” said Special Agent in Charge Tamala E. Miles of the Department of Health and Human Services Office of Inspector General (HHS-OIG). “[The defendant] was a social worker who violated the trust of her duties by accessing the personal and health data of Medicaid recipients and using the confidential information for personal gain.”
Compliance Perspective
Issue
Nursing facilities have an obligation to protect residents from financial abuse and exploitation by taking the required precautions in keeping residents’ PII as confidential as possible. Additionally, submitting false or fraudulent claims for payment to Medicare or Medicaid is illegal. Violators may face fines up to three times the programs’ loss plus $11,000 per claim filed. The civil False Claims Act considers each billed item or service as a separate claim, so fines can accumulate rapidly. 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.*
