Thursday, November 30, 2006

Medicaid Fraud in Employment

The Pennsylvania Attorney General's Office recently initiated a criminal prosecution through its Medicaid Fraud Control Section charging Medicaid fraud in an employment setting.

Medicaid fraud is a crime under Section 17 of the Medicare-Medicaid Anti-Fraud and Abuse Amendments of 1977 (Public Law 95-142), which authorized & funded states' Medicaid Fraud Control Units to investigate and prosecute provider fraud in the Medicaid program. The PA AG's Office formed its Medicaid Fraud Control Section (MFCS) in 1978.

The PA AG's Office issued a press release about its Medicaid fraud prosecution based on employment, entitled "Attorney General Corbett announces Medicaid Fraud and theft charges against York County woman accused of falsifying education credentials for mental health job":

Attorney General Tom Corbett today announced that agents from the Attorney General's Medicaid Fraud Control Section have filed criminal charges against a York County woman who was paid more than $35,000 for mental health services based on falsified information about her education and academic credentials. * * *

According to the criminal charges, MacBeth falsely claimed to have earned a Master's Degree when applying for work as a Behavioral Specialist Consultant and Mobile Therapist for two York County health care organizations. Both of those positions involve working with children who have mental health or behavioral problems and require a Master's Degree as a minimum qualification, according to the PA Department of Public Welfare. * * *

According to the criminal charges, the false educational background MacBeth provided to NHS and PCBHS caused those two agencies to pay MacBeth $35,547 for services she was not qualified to provide. Additionally, MacBeth's actions caused those two agencies to submit fraudulent claims to the PA Medicaid program totaling $49,269. Macbeth is charged with two counts of Medicaid fraud and two counts of theft by deception (creating a false impression). Each count is a third degree felony, carrying a maximum penalty of seven years in prison and a $15,000 fine.
The PA AG's website addresses its investigations into Medicaid fraud, as follows:
The main focus of Medicaid Fraud investigations concerns providers which are usually physicians, dentists, mental health clinics, drug and alcohol clinics, hospitals and health maintenance organizations. Recipient fraud is generally left to local district attorneys to prosecute.
The usual methods of Medicaid fraud are summarized in an article entitled "Investigating Health Care Fraud Within the Medicaid Program":
  • Billing for Services Not Rendered
  • Misrepresentation of Services
  • False Cost Reports
  • Kickbacks
  • Unbundling Supplies and/or Services
  • Medically Unnecessary Services and Substandard Care
  • Drug Diversion
Consistent with these usual forms of fraudulent activity, the MCFS prosecuted Medicaid fraud in 2005-06 by targeting physicians, pharmaceutical companies, and pharmacists, among others, as indicated by that Office's press releases:
However, this recent prosecution demonstrates that Medicaid fraud laws also can be violated by persons making false statements or fraudulent pretenses in their rendering of medical or care services in an employment relationship funded under the Medicaid program. If a person is convicted, the financial and imprisonment penalties are significant.

A list of the four offices (Harrisburg, Lemoyne, Norristown, & North Huntingdon) of the MCFS, with contact information, is found online
here. The AG's Office offers a pamphlet about Medicaid fraud here.

As with any prosecutions brought by the PA AG's Office, we are reminded that "a person charged with a crime is presumed innocent until proven guilty."