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Home Health & Hospice Week

Fraud & Abuse:

Authorities Focus On Medicaid Home Care Fraud

Published on Fri Dec 18, 2020

Medicaid agency owners seem to be in an egregious fraud competition.

New York Medicaid has made improvements in paying Personal Care Services claims, but it is still letting fraudulent claims slip through the payment cracks.

So says the HHS Office of Inspector General in a new report focusing on the program. The OIG reviewed a sample of 100 claims and found 28 “did not comply with certain Federal and State requirements,” it says. Problems included missing or invalid: nursing or social assessments; physician’s orders; documentation of services; and plans of care; as well as a lack of independent medical review.

“The unallowable claims occurred because New York’s monitoring of the personal care services program was not adequate to ensure that services complied with Federal and State requirements,” the OIG judges. The state did improve its program in 2017, however, the watchdog agency allows.

The cost: “We estimated that New York improperly claimed at least $54.5 million in Federal Medicaid reimbursement for personal care services during our audit period, the OIG says. And “the health and safety of some Medicaid beneficiaries may have been put at risk because their personal care aides had not undergone a criminal history check prior to providing personal care services or did not meet training requirements,” the OIG adds in the report summary at https://oig.hhs.gov/oas/reports/region2/21901016.asp.

Other Medicaid fraud and abuse developments include:

In North Carolina: Latisha Harron, co-owner of Medicaid HHA owner Agape Healthcare Systems Inc., has pleaded guilty to Medicaid and other fraud in a $13 million fraud scheme. Harron and her husband Timothy Mark Harron searched public sources such as obituaries to glean North Carolina Medicaid data for the deceased persons. If the patients had been eligible, they would “back-bill” for up to a year of services for the individuals before their deaths, the Department of Justice says.

Harron laundered the proceeds of the fraud into, among other things, a private jet, Tiffany jewelry, luxury clothing, properties in North Carolina, an Aston Martin sports car, and a wine collection, the DOJ says.

In Georgia: A former Medicaid Georgia Pediatric Program (GAPP) provider has been sentenced to five years in prison and three years’ supervised release, as well as ordered to pay $1 million in restitution. Diandra Bankhead, the owner and operator of Elite Homecare, pleaded guilty to fraud charges last August.

Amid a laundry list of misdeeds, the DOJ says Bankhead submitted claims for services that were never provided and for patients the agency never served; faked credentials; upcoded claims; billed more than 24 hours per day for employees; billed for services provided at the same time by the same employee; and faked documentation of the never-provided services.

In Pennsylvania: Another home health employee has been sentenced in the ongoing Moriarty Consultants Medicaid fraud case in Pittsburgh.

Federal and state investigators raided the Moriarty offices in 2017 and indicted 12 people, including two home health agency-owning sisters, on Medicaid fraud charges in 2018 (see HCW by AAPC, Vol. XXVI, No. 18). The case involves Moriarty and three other Medicaid HHAs, Activity Daily Living Services Inc., Coordination Care Inc., and Everyday People Staffing Inc.

Employee Terra Dean admitted that between 2011 and 2017 she was part of a scheme to submit fraudulent claims for services that were never provided, or for which there was insufficient or fabricated documentation to support the claims; that she fabricated timesheets; caused submission of claims for “ghost” employees — close relatives — for care that did not occur; and paid kickbacks to clients to participate in the fraud, according to the DOJ.

U.S. District Judge Cathy Bissoon sentenced Dean to four years of probation, including six months of home detention, and ordered her to pay more than $94,000 in restitution to Pennsylvania Medicaid, the DOJ says in a release. To date, twelve defendants have pleaded guilty for their roles in the Moriarty conspiracy, Justice says.

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