Posts Tagged ‘Medicaid fraud’

Las Vegas Firm Ordered To Pay $125,000 For Medicaid Fraud

By Nevada News Bureau Staff | 3:28 pm October 25th, 2012

CARSON CITY – A behavioral health company based in Las Vegas was fined $125,000 today in a Medicaid fraud case involving the failure to maintain adequate records to support Medicaid claims.

Rainbow Child and Family Services was sentenced for one gross misdemeanor offense of intentional failure to maintain adequate records by Clark County District Judge Valerie Adair and ordered to pay the $125,000 in restitution, penalties, and costs.

Persons convicted of Medicaid fraud may also be administratively excluded from future Medicaid and Medicare participation.

Nevada Attorney General Catherine Cortez Masto announced the sentencing.

“Businesses need to pay attention when processing Medicaid claims,” Masto said. “This office continues to investigate and prosecute Medicaid fraud cases.”

The AG’s office began an investigation after information was obtained that Rainbow was not providing services to Medicaid recipients. Interviews with Medicaid recipients showed that Rainbow was not providing the Basic Skills Training (BST) and Psychosocial Rehabilitation (PSR) services to the recipients as indicated on claims submitted to Medicaid. Furthermore, the documentation to substantiate the claims submitted to Medicaid was inadequate as the records did not note accurate or true dates or types of services provided.

The fraud occurred from August 2011 to April 2012.

The case was investigated and prosecuted by the Nevada Attorney General’s Medicaid Fraud Control Unit (MFCU), which investigates and prosecutes financial fraud by those providing healthcare services or goods to Medicaid patients. The MFCU also investigates and prosecutes instances of elder abuse or neglect.

Las Vegas Woman Sentenced in Medicaid Fraud Case

By Nevada News Bureau Staff | 11:22 am October 5th, 2012

CARSON CITY – Nevada Attorney General Catherine Cortez Masto announced today that Aurora Volero-Alvarez, 61, of Las Vegas, has been sentenced in a Medicaid fraud case involving the false reporting of personal care services.

Volero-Alvarez pled guilty to a misdemeanor offense of submission of false Medicaid claims. Justice of the Peace Melanie Andress-Tobiasson sentenced her on Thursday to 90 days jail, suspended; 40 hours of community service; a “stay out of trouble” provision; and ordered her to repay $18,450 in restitution and penalties. Persons convicted of Medicaid fraud may also be administratively excluded from future Medicaid participation.

“An anonymous tip led to this successful investigation and prosecution,” Masto said. “Our thanks go out to that person. A whistleblower sent us a letter informing my office that Volero-Alvarez had claimed she had provided services to clients who were not actually present to receive services. Tips like this one help our office ensure the integrity of Medicaid and help us return money for use by Nevadans in need.”

Attorney General Catherine Cortez Masto.

An investigation proved her patients were at other care facilities when Volero-Alvarez was claiming to have provided home bound services. Volero-Alvarez provided this false information to her employer and received payment as if she had actually performed the services. The fraud occurred from about December 2009 to February 2011.

The Medicaid PCA program enables people to live independently in their own homes by providing personal assistance with basic services, including bathing, dressing, cleaning and meal preparation. Medicaid contracts with home care companies that in turn employ individuals to provide the actual day-to-day care.

The case was investigated and prosecuted by the Attorney General’s Medicaid Fraud Control Unit, which investigates and prosecutes financial fraud by those providing healthcare services or goods to Medicaid patients.

Nevada Attorney General Announces Sentencing Of Medical Equipment Provider For Medicaid Fraud

By Nevada News Bureau Staff | 12:26 pm July 5th, 2012

CARSON CITY – Marcia Giller, 76, of Reno, has been sentenced to prison for two felony offenses of submitting false Medicaid claims, the Attorney General’s office announced this week.

Washoe County District Judge Steven Kosach sentenced Giller on Tuesday to 18 to 48 months imprisonment for each count, to be served consecutively, and additionally ordered Giller to pay $226,000 in restitution, penalties and costs.

“In addition to jeopardizing the provision of health care to people in need, medical providers who submit fraudulent claims victimize every taxpayer who funds this beneficial and necessary program,” said Attorney General Catherine Cortez Masto. “The Medicaid system must be protected, and those who commit Medicaid fraud will be punished.”

Attorney General Catherine Cortez Masto.

In December 2009, Nevada Medicaid provided information to the Attorney General’s Medicaid Fraud Control Unit (MFCU) that AME Home Health Care (AME), a medical equipment company owned and operated by Giller, had submitted and been paid for Medicaid claims that were not supported by required documentation. Medicaid provides payment to medical equipment suppliers who furnish medical supplies that allow people to maintain hygiene, gain mobility and care for their own medical conditions.

Further investigation by the MFCU revealed that, in addition to the lack of supporting documentation, Giller repeatedly submitted claims for persons who did not actually receive supplies from AME. Giller nonetheless continued to submit fraudulent claims and receive payment over the course of several years. Although Giller submitted claims under supposed client names and numbers, those persons were unaware that their Medicaid information was being used in such a way.

The fraud occurred from January 2007 through May 2010.

Persons convicted of Medicaid fraud may also be administratively excluded from future Medicaid participation.

The case was investigated and prosecuted by the MFCU, which investigates and prosecutes financial fraud by those providing healthcare services or goods to Medicaid patients. The MFCU also investigates and prosecutes instances of elder abuse or neglect.

State Agency Focuses On Waste And Abuse As Well As Fraud In Medicaid Program

By Sean Whaley | 2:00 am September 28th, 2011

CARSON CITY – It isn’t just fraud, but waste and abuse of Medicaid funds that state officials are taking aim at as the cost of the health insurance program for children, seniors and the disabled continues to climb.

Charles Duarte, administrator of the state Division of Health Care Financing and Policy, which oversees the Medicaid program, said efforts to identify fraud, waste and abuse have been stepped up since 2005 when only two staff in his office were dedicated to these important tasks.

Charles Duarte, administrator of the state Division of Health Care Financing and Policy.

Now there are nine staff devoted to such reviews, and auditors can also be brought in when there is reason to believe an in-depth analysis is needed, he said.

Called the Surveillance and Utilization Review Section (SURS), the team is another line of defense against abuses of the Medicaid program along with the Attorney General’s Medicaid Fraud Control Unit and the investigations and recovery activities within the state Division of Welfare and Supportive Services, programs highlighted in a Nevada News Bureau story published Friday.

“If you are looking at it as a pyramid it is really waste that is the big component, and then abuse and then fraud,” Duarte said.

His staff closed 290 cases in Fiscal Year 2008, a number that reached 817 in Fiscal Year 2011.

“So the numbers of cases we have currently being reviewed and investigated has grown dramatically over the last five years,” he said. “And as a result, we have been able to recover, on average, about $2 million to $3 million each year with regard to improper payments.”

Medicaid is big business in Nevada and nationally.

Nevada’s Medicaid budget for this 2012 fiscal year totals $1.6 billion, with just over $500 million coming from the state general fund. The federal government is paying 55 percent of the cost of the Nevada Medicaid program this year. Other local funds are also used to support the program.

The budget continues to grow as more Nevadans become eligible for services. In August 2009 there were just over 230,000 recipients. Two years later in August 2011 there were just over 300,000 recipients, an increase of 30 percent.

The federal government focused on Medicaid fraud in 2006 with a new law creating the Medicaid Integrity Program, identified as the “first comprehensive federal strategy” to prevent and reduce fraud, waste and abuse in the $300 billion per year program.

Concerns over Medicaid fraud have caught the attention of state lawmakers as well.

Assemblyman Cresent Hardy, R-Mesquite, proposed legislation in the 2011 legislative session to study the effectiveness of current Medicaid fraud prevention efforts and identify ways to improve efforts to combat the problem.

Assemblyman Cresent Hardy, R-Mesquite.

A contractor, Hardy testified that he identified two Medicaid fraud cases in two years in his own business. Assembly Bill 286, which had bipartisan support, did not win final approval, however.

“That’s what I wanted to look at and see how prevalent it was, and get the businesses involved to see if we could educate them in how to maybe identify this,” he said. “Because everybody that takes it illegally is taking it out of the mouths or the hands of those who really need it.”

Hardy said Duarte and other state officials need the tools to do their jobs.

“I really do believe we should be doing more to fight this thing, both at the state level and at the federal level,” he said.

Even without the review, state officials say Medicaid fraud is a priority.

Duarte’s staff spends much of its time analyzing data looking for “statistical outliers” or deviations in the normal parameters of billing activity, to identify potential areas of concern.

“And so we do a lot of the work up front for other branches of state government that may be involved either in prosecution or recipient-level fraud,” Duarte said. “So we’re the front line with regard to those types of reviews.”

There is also a deterrence effect from the reviews, he said.

“The word gets around,” Duarte said.

Some cases are resolved with education of a provider or group of providers, he said. But repeat offenders could be audited to recoup excess payments. If there is criminal intent, then the case is referred for potential prosecution, Duarte said.

There is also prospective review, such as checking the status of a provider seeking to do business with the Medicaid program in Nevada, he said. There have been cases where a business has been shut down for bad acts, but the same individuals establish a new company in an effort to continue to provide Medicaid services, Duarte said.

Fraud cases can involve a variety of activities, including providers who bill for services that are not even provided, he said.

In 2010 for example, the agency cut off all payments to Ujima Youth Services, which operated group homes at several locations in Reno, after an audit showed the company’s records did not support the amount that was billed to Medicaid. The Secretary of State’s Office shows there is no longer any active business entity by that name in Nevada.

“You want folks to have an appreciation that we appreciate their tax dollars and how (they are) being used,” he said. “It’s really an issue of stewardship on our part and on the part of the federal government.”

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Audio clips:

Charles Duarte, administrator of the state Division of Health Care Financing and Policy, says his office looks at waste, abuse and fraud:

092711Duarte1 :23 and then fraud.”

Duarte says his staff does a lot of the upfront work looking into Medicaid fraud:

092711Duarte2 :10 recipient level fraud.”

Duarte says his staff have been able to recover between $2 million and $3 million in improper payments:

092711Duarte3 :20 to improper payments.”

Assemblyman Cresent Hardy says more needs to be done to fight Medicaid fraud:

092711Hardy1 :31 the suppliers themselves.”

Hardy says those who illegally receive Medicaid take it from those who really need it:

092711Hardy2 :15 really need it.”