Submitting claims for Medicaid reimbursement for behavioral healthcare services that did not occur violates the false claims act; then, fabricating false medical records when those claims are questioned compounds the fraud committed
Compliance Perspective
Policies/Procedures: The Compliance and Ethics Officer with the Business Office Manager will review policies and procedures that are in place for ensuring that patients’ medical records used to support claims submitted to Medicare and Medicaid for reimbursement contain accurate and complete documentation and have not been fabricated or falsified.
Training: The Compliance and Ethics Officer with the Business Office Manager will ensure that staff are trained about and understand the importance of accurate and complete documentation and not fabricating or falsifying medical records even if asked to do so by a supervisor or a company executive.
Audit: The Compliance and Ethics Officer with the Business Office Manager should personally conduct an audit of medical records used for billing Medicare and Medicaid to determine if they are accurate and complete and not falsified in any manner to secure reimbursement for services not provided.
Two executives of a behavioral healthcare provider pleaded guilty in U.S. District Court to the charge of Conspiracy to Commit Health Care Fraud, in violation of Title 18 of the U.S. Code, Section 1349. The case involves a scheme to defraud the South Carolina Medicaid program. The owner of the behavioral healthcare provider was previously prosecuted for healthcare fraud in North Carolina and was sentenced in July to 96 months in federal prison. The two defendants were also involved in the North Carolina fraud scheme that used stolen names and identifiers of North Carolina employees to defraud the North Carolina Medicaid program.
Evidence in the South Carolina Medicaid fraud showed that from October 2013 to November 2014, the behavioral healthcare provider fraudulently billed South Carolina Medicaid for more than $595,000 in fictitious services. When the defendants were contacted in 2014 about the billings, they fabricated records to support those prior billings. After that, from December 2014 to April 2015, they received another$1.4 million from the Medicaid program for fictitious behavioral healthcare services.
In 2015, after another audit, the South Carolina Medicaid program contacted the behavioral healthcare provider and requested support billings for 160 different patients. Instead of admitting that the services were fraudulent, the defendants oversaw the fabrication of all 160 requested records. They used names from the company’s North Carolina behavioral healthcare provider to create fake profiles. Then,they fabricated medical records to justify the prior billings to Medicaid and make it appear that there were individuals working at the South Carolina provider’s facility when that had never occurred.
The defendants defrauded the South Carolina Medicaid program of nearly $2 million. They face up to 10 years imprisonment for their roles in the scheme plus potential fines,supervised release, and mandatory restitution.
