On January 19, 2022, the Massachusetts Medicaid Fraud Division announced that in calendar year 2021, more than $55 million was recovered from individuals and entities who defrauded the state.
The Attorney Generalās Medicaid Fraud Division investigates and prosecutes providers who defraud the state Medicaid program, MassHealth. The Medicaid Fraud 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 settings.
In 2021, the Division secured 22 civil settlements with various entities, including home health agencies, substance abuse treatment facilities, adult day health centers, adult foster care providers, skilled nursing facilities, and dental practices.
Most of the money recovered was returned to MassHealth, but some was returned to the Department of Public Healthās Long Term Care Facility Quality Improvement Fund; to patients who had paid out of pocket for services that should have been covered by MassHealth; to the federal Medicare program; and to whistleblowers who brought lawsuits against providers alleging fraud.
The Medicaid Fraud Division also prioritizes the physical and financial security of residents who reside in Massachusetts nursing homes. Cases include:
- In September 2021, a certified nurseās aide was charged with sexually assaulting two elderly nursing home residents at a Massachusetts nursing home while he worked the night shift.
- In August 2021, a former business office manager at a Massachusetts nursing home pled guilty and was sentenced to jail in connection with stealing tens of thousands of dollars from elderly residents.
- In April 2021, the former admissions director at a different Massachusetts nursing home pled guilty to engaging in an embezzlement scheme to steal tens of thousands of dollars from an elderly resident.
- A Massachusetts rehabilitation and nursing home agreed to pay $110,000 to resolve allegations that it failed to adequately meet the needs of and appropriately care for residents.
- A Massachusetts care center agreed to pay $90,000 to resolve allegations that it committed neglect of a resident, which resulted in the residentās death, and that it failed to comply with regulations requiring nursing staff to have adequate competencies to care for residents in emergency situations.
Attorney General Maura Healey stated, āAddressing fraud and misconduct in the health care sector is a top priority for my office, and we will continue this important work in 2022.ā
Issue:
The Centers for Medicare & Medicaid Services (CMS) requires skilled nursing facilities to have a compliance and ethics program that is effective in preventing and detecting criminal, civil, and administrative violations under the Social Security Act, and in promoting quality of care. Routine audits should be conducted on monetary transactions, and the results of the audits should be reported to the compliance and ethics committee and to the governing body. The audits should have a corrective action plan when a discrepancy is found, and all discrepancies should be investigated and rectified immediately. It is imperative that every facility has an effective compliance and ethics committee to reduce the likelihood of healthcare fraud, waste, and abuse of government funds. Additionally, each facility must actively strive to prevent abuse, neglect, and exploitation of residents, and misappropriation of resident property or funds from occurring.
Discussion Points:
- Review your policies and procedures for operating an effective Compliance and Ethics Program and for preventing resident abuse, neglect, exploitation, and misappropriation of personal property and funds. Ensure that your policies are reviewed at least annually and updated when new information becomes available.
- Train all staff upon hire and at least annually on your compliance and ethics policies and procedures for preventing and detecting fraud, waste, and abuse; on your abuse, neglect, exploitation, and misappropriation prevention protocols; on their responsibilities for preventing violations from occurring; and that timely reporting of concerns is mandatory. Document that these trainings occurred, and file the signed document in each employeeās education file.
- Periodically perform audits to ensure all staff are aware of compliance, ethics, and abuse/neglect prevention protocols and understand their responsibilities to report any violations to their supervisor, the compliance officer, or via the anonymous hotline.
