A South Dakota woman was convicted by a jury on charges of three counts of healthcare fraud and two counts of aggravated identity theft in the United States District Court for the District of Wyoming. In March 2020, the woman was indicted on the charges, which included three overlapping schemes to defraud Wyoming Medicaid by submitting false claims for long-term care provided to the woman’s sibling, and the unlawful possession and use of identity information of two individuals in furtherance of two of the charged schemes.
The evidence at trial showed that Wyoming Medicaid operates a long-term care program designed to keep beneficiaries out of nursing homes and other institutional settings. This program includes limited payments for certain direct support services provided to beneficiaries by properly qualified and enrolled workers. The convicted woman enrolled her niece in this program as a caregiver for the convicted woman’s sister using the niece’s name, social security number, and other identifying information. The convicted woman then submitted claims to Wyoming Medicaid for direct support work using the niece’s name when the niece had not provided any services. The convicted woman’s niece did not know her identity was being used and had never been to Wyoming before testifying at trial. The false information provided by the convicted woman caused Wyoming Medicaid money to be paid in the niece’s name into a credit union account controlled by the convicted woman.
Evidence at trial also proved that the convicted woman advertised for a direct support worker. When a young woman responded to the ad, the convicted woman convinced her to give her social security number and other identification information to her to be hired for the job. The woman worked one day, was paid cash for her time, and was not asked to return. The young woman did not know that she was enrolled with Medicaid or that her information was used for that purpose. However, the convicted woman then used the young woman’s information to submit false claims to Wyoming Medicaid for direct support work that the woman did not perform. The false information provided by the woman caused Wyoming Medicaid money to be paid in the young woman’s name into a credit union account controlled by the convicted woman.
Finally, evidence at trial proved that the convicted woman enrolled herself as a direct support worker when she had a power of attorney for her sister, and therefore could not be enrolled under Medicaid’s long-term care rules. The convicted woman then submitted claims to Wyoming Medicaid for direct support work when she was not eligible to be paid for this work. As a result, Wyoming Medicaid money was paid to the convicted woman when she was not eligible to receive that money.
The convicted woman may be sentenced to not more than 10 years in prison for each healthcare fraud count and must be sentenced to a mandatory 2-year prison term for each identity theft count. The 2-year identity theft prison sentences must be consecutive to any prison term imposed for the healthcare fraud counts but may be imposed concurrent to one another. A fine of up to $250,000 could also be imposed for each count.
Suspected fraud against Medicaid can be reported to the U.S. Department of Health and Human Services’ Office of Inspector General at 1-800-HHS-TIPS (1-800-447-8477) and the agency’s website https://oig.hhs.gov/fraud/report-fraud/. Wyoming residents can call the Wyoming Medicaid Fraud Control Unit toll free at 1-800-378-0345, or visit their website at http://ag.wyo.gov/medicaid-fraud-control-unit.
Issue:
It is the obligation of each nursing facility to protect residents from financial abuse and exploitation by taking the required precautions in keeping residents’ personal information as confidential as possible. If residents’ personal information is exposed in a data breach, it is the responsibility of the facility to report the breach as soon as it is discovered. Residents are more likely not to know that they have been a victim of identity theft. In addition, all members of the healthcare team should be aware of what is considered a false claim. Ensure that all staff are aware that these violations can occur whether they are intentional or not intentional. Failure to promptly report a false claim can result in lawsuits, fines, and other sanctions. Additional information is available in the Med-Net Corporate Compliance and Ethics Manual, Chapter 2 Financial Integrity, CP 2.3 General Legal Duties and Antitrust Laws. Additional information about identity theft is available in Chapter 5 Privacy Plan, PP 2.4 Identity Theft.
Discussion Points:
- Review your policies and procedures on protecting residents’ personal information and preventing financial abuse and exploitation. Also review your policies and procedures for preventing and reporting a false claim. Update your policies if needed.
- Train all staff who have access to resident’s personal information on your policy and procedure for protecting resident’s personal information. Also train all staff on the False Claims Act and what can be considered a false claim. Include information on how to report concerns and suspected violations, and that prompt reporting is mandatory. Document that the trainings occurred and file the signed documents in each employee’s education file.
- Periodically audit to ensure that staff who have access to residents’ personal information are aware of the proper procedures to follow to prevent personal information exposure. Also, periodically audit staff to ensure that they are aware of what should be done if they suspect a false claim has occurred, whether intentionally or unintentionally. Periodically audit staff understanding to ensure that they are aware of what constitutes resident financial abuse and exploitation, what they should do if they suspected it is occurring, and the legal and employment penalties for exploiting residents.
