Medicaid Fraud
Do we have to?
MEDICAID FRAUD
Federal & State authorities are prosecuting vigorously and systematically
Why?
“The Lie for Money” … Big money at stake
In PA for 2007, 1.9 million recipients; $14.6B; 68,000 providers
Deficit Reduction Act of 2005
Provided resources to CMS for the prevention, earlier detection and
reduction of fraud, waste and abuse in the $300 billion Medicaid
program.
DRA 2005 requires each provider attest compliance annually
What is Medicaid fraud?
EXAMPLES OF MEDICAID
FRAUD & ABUSE
• Billing for services not rendered
• Altering claims
• Submission of any false data on claims, such as date of service,
destination, provider or prescriber of service
• Duplicate billing for the same service
• Providing unnecessary services/overutilization
• Kickbacks-accepting or making payments for referrals
• Billing for services provided by unlicensed or unqualified persons
• Balanced billing – charging recipients for MA covered services
• Falsified Timesheets
• Falsified application
• Beneficiary’s condition/diagnosis
• Embezzlement
FEDERAL STATUTES RELATED
TO HEALTHCARE
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18 USC 1035 – False Statements
18 USC 1341 – Mail Fraud
18 USC 1347 – Health Care Fraud
18 USC 3729 – False Claims
18 USC 2
– Aiding and Abetting
18 USC 669 – Theft, Embezzlement
18 USC 1518 – Obstruction
•
Your signature certifies that I
received/provided a service or item on
the date listed above. I understand that
payment for this service or item will be
from Federal and State funds, and that
any false claims, statements, or
documents, or concealment of material
facts may be prosecuted under
applicable Federal and State laws.
PA STATUTE RELATED
TO CARE
18 Pa.C.S.A. – 2713(a)
Neglect of Care-Dependent Person
Who is subject to prosecution?
Owner, Operator, Manager or Employee of a:
Nursing Home - Personal Care Home - Community Residential Facility
Adult Daily Living Center - Home Health Service Provider
Prohibited –
• Intentional, knowing or reckless causing of injury
• Failing to provide care necessary to preserve health & safety of consumer
• Intentional use of a physical or chemical restraint, medication or
isolation which results in injury
Penalties - 5 years, $10,000 or 20 years, $25,000
PENALTIES FOR
MEDICAID FRAUD OR ABUSE
Prison
Restitution
Fines, Penalties
Lost Licenses
Exclusion
Obviously something you don’t want to be involved in; but
what if you think something fishy is going on?
REPORT IT!
Who do you call?
Sue Morse, Susquehanna Attendant Care Program Manager
1-717-737-3477
DPW Hotline
1-866-379-8477
or
Office of Attorney General
Medicaid Fraud Control Unit
1-717-783-1481
Email
FDRCompliance@ucpcentralpa.org
omaptips@stat.pa.us
Web
http://dpw.state.pa.us/omap
REPORT IT!
How will you be protected?
Anonymous reporting okay
Protected under UCP Central PA
“Whistleblower” Protection Policy
Medicaid Fraud Control Act
1407(a)(1): False Claims – present a false claim or cost report, or
present a claim for unnecessary services or any false information to
obtain greater compensation
1407(a)(4) Services Not Rendered – submit a claim for services,
supplies or equipment which were not rendered to a recipient
1407(a)(6): Below Accepted Medical Treatment – submit a claim for
services which are below accepted medical treatment standards
1407(a)(7): Misrepresentation – submit a claim that misrepresents
the services provided; the dates of service; identity of the recipient;
attendant or provider
1407(a)(12) Conspiracy – enter into an agreement or conspiracy to
obtain or aid another to gain reimbursement for which there is not
entitlement
Penalties: 7-years imprisonment; $15,000 fine; Ineligible for Medical
Assistance program for 5-years
Medicaid Integrity Program
Deficit Redution Act of 2005
Provided resources to CMS for the prevention, earlier detection and
reduction of fraud, waste and abuse oin the $300 billion Medicaid program.
How to combat fraud? – REPORT IT!
In PA Medical Assistance Program –
In 2007, 1.9 million recipients; $14.6B; 68,000 providers
FADS – Fraud and Abuse Detection System – data analysis to profile
providers to identify abnormalities or patterns of misuse.
PA DPW Bureau of Program Integrity
PA Attorney General – Medicaid Fraud Control Section
US Department of HHS – Office of Inspector General
cards.
Barbara M. McClinton, 45, obtained identifying information about the woman while she was
employed as a home health care provider for her in 2005, according to Glenn Suddaby, U.S.
attorney for the Northern District of New York.
McClinton used the information to obtain at least three credit cards, with which she bought
$30,000 worth of items, including three cars, car insurance, cell phone services, gas, food, and
clothing, Suddaby said.
The Times
Health aide charged with stealing patient's jewelry
by Debra Friedman
PRINCETON TOWNSHIP -- A 36-year-old Trenton woman working as a home heath care aide was
arrested Sunday afternoon, after it was revealed she stole $1300 worth of jewelry from a 93-yearold patient who lives on Mount Lucas Road, police said.
Shadoe Inman of the 300 block of Commonwealth Avenue was arrested at her home at 1:30 p.m.
Sunday and charged with theft.
Police said an investigation conducted by Detective Sgt. Scott Porreca and Officer Jennifer Lacovara
tied Inman to the crime, which took place sometime between Aug. 18 and Sept. 15.
Police said Inman stole the jewelry while providing care to the elderly woman.
Inman will be arraigned Oct. 2 at the township municipal court.