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Two private Massachusetts health care providers have entered into settlements totaling more than $10 million over Medicaid fraud cases. Both of the Boston-area businesses have been charged with false billing of the Bay State’s Medicaid program, according to Attorney General Maura Healy.
One of the companies, Avenue Homecare Services, Inc., will reportedly pay $8.3 million, while the other defendant, Amigos Homecare LLC, is on the hook for $2.1 million.
In addition to the settlements, both companies have been required to adopt long-term compliance programs, subject to the oversight of an independent third party. They will need to update their policies and procedures on how they plan to follow state and federal regulations, and ensure that all employees are familiar with them.
Both companies will also be subject to yearly audits and monitoring by the Massachusetts Attorney General’s office.
Specific Allegations
Healy says that in both Medicaid fraud cases companies “defrauded the state and diverted vital resources from elderly and disabled patients…in both cases, the AG’s Office alleges that these health care companies billed for services for which they did not have valid, signed plans of care.”
This would be in violation of state regulations that require any contractor that bills the Massachusetts Medicaid program, MassHealth, must provide a written plan certifying that the services provided are medically necessary. This plan must be signed by the patient’s physician. Furthermore, these contractors are required by law to retain records of these services for no less than 6 years.
Oversight – or Scam?
In the case of Amigos Homecare, the Massachusetts AG’s office alleges that the company submitted “fake claims” for nearly 4 years between June 2014, and April 2018.
The investigation revealed that a number of these claims were submitted for patients who were actually in hospitals, not receiving care and treatment at their homes. Amigos had been Medicaid-certified for only six months at the time the alleged violations began.
Avenue Homecare also allegedly billed MassHealth for providing home care services to patients who were hospitalized at the time – and the services had not been authorized by a physician as required under the law.
Medicaid Fraud Cases Are an Ongoing Problem
This has not been the first time that the State of Massachusetts has had to deal with Medicaid fraud cases or whistleblower lawsuits. In February 2018, South Bay Mental Health Center, Inc. wound up paying $4 million to settle allegations of billing the state’s Medicaid program for services delivered by employees who lacked credentials, qualifications, and supervision.
In August of that year, the owner of Harmony Health Care LLC was convicted of three counts of Medicaid fraud and given a 3-year prison sentence, according to the Boston Business Journal. Three months later, a couple entered a guilty plea of defrauding MassHealth by billing for home care to a person who was deceased.
Massachusetts is not the only state where this is happening. It is one of the major problems that are unique to the U.S. profit-driven health care model; the lure of easy money from deep government pockets is too great a temptation, and only by removing the profit motive from health care might this egregious behavior end.
In the meantime, if you are aware of Medicaid fraud, you may benefit from a consultation with a knowledgeable whistleblower attorney. Federal law provides for financial incentives, along with whistleblower protection, for those who are willing to come forward.
