On December 1, 2021, a woman from Pittsburgh, Pennsylvania, was sentenced in federal court for conspiracy to defraud the Pennsylvania Medicaid Program, healthcare fraud, and aggravated identity theft.
During her plea hearing on March 13, 2020, the Pittsburgh woman admitted that at various times between 2011 and 2014 she was an employee of four different home health agencies, of which three of the entities were related. The four home health agencies were approved under the Pennsylvania Medicaid Program to offer certain services to qualified Medicaid recipients, which included personal assistance services (PAS), service coordination, and non-medical transportation, as well as other services.
Between January 2011 and the woman’s departure from the entities in 2014, three of the home health agencies collectively received tens of millions of dollars in Medicaid payments based on claims submitted for home health services, with PAS payments accounting for the vast majority of the total amount. The Pittsburgh woman admitted that she participated in a wide-ranging conspiracy to defraud the Pennsylvania Medicaid program for the purpose of obtaining millions of dollars in illegal Medicaid payments through the submission of fraudulent claims for services that were never provided to the consumers identified on the claims, or for which there was insufficient or fabricated documentation to support the claims.
Additionally, the woman admitted that she fabricated timesheets to reflect the provision of in-home PAS care that, in fact, she never provided to the consumer identified on the timesheets. In one instance, she admitted submitting false timesheets claiming that she provided more than 80 hours of care in a single week to a consumer, while also working full-time as the nominal president of one of the home health agencies. Also, during a two-year period in which the same consumer lived with the Pittsburgh woman, she admitted to taking steps to conceal from Medicaid their co-habitation and that she served as the consumer’s power of attorney (both disqualifying circumstances).
Also, the woman admitted that she paid kickbacks to at least one consumer—her then spouse—in exchange for his participation in the scheme. Specifically, she admitted that she and her father, who is also a co-defendant, used her father’s name on time sheets for fabricated care of her then-spouse. The woman, her father, and her spouse would meet at the office of one of the home health agency when payment was received for the fraudulent care so that they could divide the proceeds. In total, the woman acknowledged causing losses to the Pennsylvania Medicaid program in excess of $250,000 related specifically to her spouse.
The woman also caused the submission of Medicaid claims for PAS care that her friend, one of the home health agency’s employees, purportedly provided to various consumers, without the friend’s knowledge, and when in fact no such care had been provided to the consumers. The friend, in fact, was recovering from a serious injury and unable to work during the time the billing occurred. The Pittsburgh woman misused her friend’s personally identifiable information to obtain and misappropriate resulting salary payments. Finally, she admitted that during the course of audits of three of the home health agencies, she fabricated documentation for submission to state authorities in an effort to conceal the Medicaid fraud scheme. Among other things, she fabricated PAS timesheets, criminal history checks for attendants, child-abuse clearance forms for attendants, and certain consumer affidavits to ensure that files requested as part of the audits appeared complete.
The Pittsburgh woman was sentenced to sixty-five months of imprisonment, followed by two years of supervised release, for her role in a years-long conspiracy. She was also ordered to pay restitution to the Pennsylvania Medicaid program in the amount of $445,131.67.
As of now, a total of sixteen defendants have been charged in connection with this investigation. The Pittsburgh woman was the twelfth defendant to enter a guilty plea.
Compliance Perspective
Issue
The Centers for Medicare & Medicaid Services (CMS) requires skilled nursing facilities to have a Compliance and Ethics Program that is effective in preventing and detecting criminal, civil, and administrative violations under the Social Security Act, and in promoting quality of care. Routine audits should be conducted of all monetary transactions, and the results of the audits should be reported to the Compliance and Ethics Committee and to the governing body. The audit results should include a corrective action plan if a discrepancy is found, and all discrepancies should be investigated and rectified immediately. It is imperative that every facility have an effective Compliance and Ethics Committee to reduce the likelihood of healthcare fraud, waste, and abuse of government funds.
Discussion Points
- Review your policies and procedures for operating an effective Compliance and Ethics Program. Ensure that your policies are reviewed at least annually and updated when new information becomes available.
- Train all staff on your compliance and ethics policies and procedures upon hire and at least annually thereafter. 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 protocols and understand their responsibility to report any concerns or violations to their supervisor, the compliance and ethics officer, or via the anonymous hotline.
