Massachusetts Attorney General Maura Healey announced that her office’s Medicaid Fraud Division recovered more than $71 million during the most recent federal fiscal year, which ended on September 30. The AG’s Medicaid Fraud Division investigates and prosecutes providers who defraud the state’s Medicaid program, MassHealth. The Division is also responsible for reviewing complaints of abuse, neglect, mistreatment, and financial exploitation of patients in long-term care facilities and MassHealth members in any healthcare setting.
During the most recent federal fiscal year, the Division secured 35 civil settlements with various entities, including outpatient mental health providers, home health agencies, substance abuse treatment facilities, adult day health centers, skilled nursing facilities, and dental practices. The overwhelming majority of the Division’s recoveries were returned to MassHealth. Funds were also returned to the Opioid Recovery and Remediation Fund — a fund established by the Legislature in 2020 with money from AG Healey’s opioid litigation and settlements, to mitigate the impacts of the opioid epidemic in Massachusetts; the Department of Public Health’s Long-Term Care Facility Quality Improvement Fund; former employees of MassHealth providers who were owed unpaid wages; and whistleblowers who brought lawsuits against providers alleging fraud.
The Division brought criminal charges against 24 providers and individuals for defrauding MassHealth and two individuals for abuse, neglect, or financial exploitation of elders. The Division also secured criminal indictments against a variety of providers and individuals, including physicians, clinical laboratories, mental health providers, personal care attendants, and home health aides.
You can read about some of the cases here.
Issue:
Skilled nursing facilities are required to have a compliance and ethics program that is effective in preventing and detecting criminal, civil, and administrative violations to reduce the likelihood of fraud, waste, and abuse of government funds. More information is available in F895 Compliance and Ethics Program in the State Operations Manual, Appendix PP, available at this link: SOM – Appendix PP (cms.gov).
Discussion Points:
- Review your policies and procedures for operating an effective compliance and ethics program. Ensure that your policies are reviewed at least annually and updated when new information becomes available.
- Train all staff on your compliance and ethics policies and procedures upon hire and at least annually. Ensure that they understand that an effective compliance and ethics program is everyone’s responsibility. Document that these trainings occurred and file the signed document in each employee’s education file.
- Periodically perform audits to ensure that all staff are aware of compliance and ethics policies and guidelines and understand their responsibility to report any concerns to their supervisor, the compliance and ethics officer, or via the anonymous hotline. Provide the audit information and any necessary action steps to the compliance and ethics committee and the governing body.
