Compliance Perspective – Medicaid Fraud:
The Compliance Officer should review the facility’s policy and procedures regarding Medicare Billing and prohibited billing practices with the Administrator and the MDS Coordinator. Staff should receive education and training on reporting suspected billing violations to an immediate supervisor or through the Compliance Hotline. The Compliance Officer is responsible to ensure that periodic audits are conducted that are designed and implemented to discover discrepancies in billing and coding and ensure that services being billed were actually performed and overseen by appropriate staff.
The owner of a home care service provider and her son received a $3 million judgment for their participation in a fraud scheme perpetrated on the North Carolina Medicaid program in violation of the federal and North Carolina False Claims Acts.
Trial evidence revealed that between 2008 and 2013, the facility billed the North Carolina Medicaid program for $585,082.73 in fraudulent claims. These claims included not only claims for services provided in violation of Medicaid policies, but also for claims for services that were not provided. When the government began investigating the owner and her son, falsified hundreds of documents trying to conceal the fraud.
Prior to the trial, the Chief Judge found that the defendants w
ere liable for their participation in the scheme and that they “knowingly billed for services not rendered, knowingly billed for certain services provided to patients by unlicensed, non-certified aides, and knowingly billed for certain services provided to patients by close family members.” The judge also found that the defendants “falsified documents to conceal their obligation to repay the government and used false documents to support false claims previously submitted.”
The nearly $3 million judgment was determined under the requirements of the federal and North Carolina False Claims Acts that require a recovery that is three times the damages caused by the fraud, plus civil penalties for every false or fraudulent claim
