Pennsylvania Attorney General Dave Sunday announced on June 13 that the owner of a Berks County-based home care agency was sentenced to prison, parole, and probation, and was ordered to pay $235,778 in restitution, for collecting Medicaid reimbursement based on fraudulent claims submitted by his company.
An Office of Attorney General investigation, including a presentment from the 47th Statewide Investigating Grand Jury, determined that the agency received Medicaid funds for services that were not provided and for claims containing false information.
The owner of the company, a 36-year-old New York resident, previously pleaded guilty to felony Medicaid fraud and perjury, as well as a separate count of Medicaid fraud on behalf of the company. He was sentenced to one month in prison, followed by 22 months of parole and five years of probation.
As part of sentencing, both he and his business will be excluded from participation in the Medicaid program for at least five years. A federal healthcare exclusion is also anticipated.
The investigation found that, between 2020 and 2022, the owner and his company submitted claims to Medicaid for services that were either misrepresented or never performed. Some claims involved individuals who had not enrolled with or received care from the agency, while others involved employees who were unaware that false claims had been submitted under their names.
The Grand Jury investigation also found that the owner gave false testimony about payroll records.
Compliance Perspective
Issue
It is illegal to submit claims for payment to Medicare or Medicaid that you know or should know are false or fraudulent. Under the False Claims Act, each individual item or service billed may be considered a separate violation, with potential civil and criminal penalties, including fines, restitution, and exclusion from participation in state and federal healthcare programs. Submitting claims for services not provided, falsifying documentation, or misrepresenting staff activity constitutes fraud. Providers must implement safeguards to ensure claims are accurate, supported by documentation, and based on services actually delivered.
Discussion Points
- Review policies and procedures to ensure they address accurate documentation and appropriate billing practices for claims submitted to Medicaid and other government healthcare programs. Include guidance on reporting suspected fraud or billing concerns, along with the potential consequences of noncompliance.
- Provide mandatory training for staff upon hire and at least annually on compliance requirements, including what constitutes a false or fraudulent claim. Reinforce staff responsibility to report concerns through appropriate channels, and maintain a nonretaliatory environment for doing so.
- Conduct regular audits of billing records and documentation to verify the accuracy of claims submitted. Include checks for unauthorized or unsupported services, and ensure that no excluded individuals or entities are involved in billing or service delivery. Take corrective action as needed when discrepancies are identified.
*This news alert has been prepared by Med-Net Concepts, Inc. for informational purposes only and is not intended to provide legal advice.*