Medicaid

December 2, 2013

Caremark agreed to pay $4.25M to settle allegations that it knowingly failed to reimburse Medicaid for prescription drug costs paid on behalf of Medicaid beneficiaries, who also were eligible for drug benefits under Caremark-administered private health plans. The allegations were first raised in a qui tam lawsuit filed under the whistleblower provisions of the False Claims Act. DOJ

January 21, 2016

New York will receive $47 million in a settlement with CenterLight Healthcare and CenterLight Health System, resolving allegations that CenterLight Healthcare’s Select Medicaid Managed Long Term Care Plan fraudulently billed Medicaid for services they did not provide to more than 1,200 Medicaid recipients. Under the settlement, CenterLight Healthcare admitted that it enrolled Medicaid beneficiaries who were referred by social adult day care centers even though the beneficiaries were not eligible to receive managed long-term care under the plan, and that the centers were providing services that did not qualify for reimbursement under New York State Department of Health standards, or CenterLight’s contract with DOH.  Whistleblower David Heisler will receive a yet-to-be-determined whistleblower award. NY

October 7, 2015

In New York, two individuals who owned and operated two transportation companies, were arrested for allegedly violating the Workers’ Compensation law and illegally obtaining over $1 million from the Medicaid system. Yellow Medi-Van and Taxi, Inc. received payments from the Medicaid Program for transporting Medicaid beneficiaries to medical appointments. The defendants are alleged to have knowingly operated the company in violation of transportation regulations, including not having worker’s compensation insurance. During the time the company was operated unlawfully, the companies obtained over $1 million in Medicaid payments. NY

September 29, 2015

The New Jersey Medicaid Fraud Control Unit and Office of the Insurance Fraud Prosecutor obtained an indictment against a doctor, Syed Jaffery, for accepting kickbacks in exchange for patient referrals. The indictment alleges that from 2010 to 2013, Jaffrey participated in a scheme by which he agreed to refer patients needing MRI and CT scans to Diagnostic Imaging Services of South Jersey in exchange for monetary kickbacks. Over the course of the scheme, Jaffrey allegedly accepted approximately $195,000. In an attempt to disguise the arrangement, the kickback checks were made payable to Jaffrey’s alleged shell company Mask Realities and purported to be for a rental space for billing services. NJ

September 10, 2015

The Washington Attorney General announced a suit against CareOne Dental Corporation and related individuals for Medicaid fraud. The suit alleges that the defendants systematically billed Medicaid for non-covered services which they misrepresented in their billings, “upcoded” services (more expensive versions of what they actually performed), and services they simply didn’t provide. The Attorney General’s Office currently estimates at least 20 percent of the claims CareOne Dental presented to Medicaid from January 2011 to June of 2015 were fraudulent, which would amount to approximately $1 million in single damages. WA

August 4, 2015

Pediatric Services of America, Inc., reached a $2.7 million federal-state settlement resolving allegations that the company inappropriately failed to return overpayments received from state Medicaid programs as well as other federally insured health programs. PSA is also alleged to have overcharged for home nursing services by improperly rounding-up claims to the nearest whole hour. Connecticut Department of Social Service Commissioner Roderick L. Bremby said, “This settlement exemplifies the outstanding work across the state and federal governments to obtain compensation for the taxpayer-funded Medicaid program when medical providers cross the line.” CT

July 29, 2015

New York Attorney General Eric T. Schneiderman announced the sentencing of the executive director of a company for stealing funds from the Nursing Home Transition and Diversion program, a Medicaid-funded program that provides senior citizens and those suffering from physical disabilities an alternative to institutional living through the use of Medicaid funds for renovations to the homes of the elderly and disabled (wheelchair ramps, grab bars, etc.). Defendant plead guilty to grand larceny, based on the submission of bids and cost reports, which falsely stated the actual costs of the projects, significantly inflating the actual costs or including services which were never provided. NY

July 20, 2015

Following a jury trial, Humphrey Udeh was convicted of defrauding New York’s Medicaid program of over $1 million. Udeh billed the state for over three thousand units of a highly-specialized and expensive liquid pediatric nutritional formula, when he actually dispensed over-the-counter nutritional supplement formulas. In order to perpetuate the scam, Udeh utilized generic prescriptions of pediatric formula and false letters of medical necessity, obtained by employees of his company, Advanced Medical Supply, from unsuspecting physician and medical facilities. He then used the generic prescriptions and false letters to support his fraudulent claims. Udeh was sentenced to serve 7 to 21 years in state prison and pay a $1.7 million fine. NY

July 15, 2015

A Hawaii administrative panel determined that Liberty Dialysis was overpaid over $7 million for treatments given to Medicaid patients between 2006 and 2010. While the Attorney General stated that the original overpayments were the result of a state computer error, Hawaii also announced that it was pursuing litigation against Liberty, which is alleged to have known it was being overpaid and continued to submit claims in a way designed to continue those overpayments. HI

July 6, 2015

New York announced a $400,000 settlement with a transportation company that was unable to provide documentation for services it had billed to Medicaid. “Providers must be able to properly document services for which they received payment from Medicaid,” said Attorney General Schneiderman. “Doing otherwise drains Medicaid of precious resources, and my office will steadfastly guard New York taxpayer dollars expended to ensure quality care to those most in need.” NY