On July 13, 2021, a New Hampshire home care owner pled guilty and was sentenced to two counts of class B felony Medicaid fraud, and a third charge of Medicaid fraud. The home care company is licensed to provide in-home personal care services to Medicaid beneficiaries.
Between January 2015 and December 2018, the home care owner submitted claims for reimbursement for in-home, personal care services that were never actually provided, and included periods when the home care clients were either in hospitals or nursing homes. Additionally, beginning in December 2015 the home care owner billed Medicaid up to the maximum hours allowed under certain client’s service authorizations. The home care owner was aware that his employees did not actually provide care for all those hours, and he would use the revenue difference to reimburse caregivers for mileage.
The home care owner was sentenced to serve twelve months in the Arkansas House of Corrections with a recommendation for administrative home confinement and ordered to pay $1,000,000 in restitution. Additionally, the home care company is now excluded from future participation in federal healthcare programs.
Issue:
Fraud, waste, and abuse of federal and state funds is always illegal. It is imperative that all staff members are trained and well versed in what constitutes fraud, waste, and abuse of federal and state funds. In addition, all staff members should be trained and knowledgeable on how to report any suspicion of fraud, waste, or abuse of government funds. Fraud, waste, and abuse violations can result in fines, placement on the OIG List of Excluded Individuals and Entities, and civil penalties including prison time. Detailed information on this topic is available in the Med-Net Corporate Compliance and Ethics Manual, Chapter 1 Compliance and Ethics Program and in Chapter 2 Financial Integrity.
Discussion Points:
- Review all policies and procedures that pertain to fraud, waste, and abuse of federal and state funds. Update policies and procedures as needed.
- Train all staff on what may be considered fraud, waste, and abuse of federal and state funds, and the steps that they should take if they suspect this is occurring, including that reporting is a mandatory responsibility.
- Periodically audit staff members’ understanding to ensure that they are knowledgeable about what constitutes fraud, waste, and abuse of federal and state funds, and how they can report suspicions of this activity.
