On April 25, 2022, a former owner of multiple Texas adult day care centers was sentenced to 60 months in prison and ordered to pay $1,784,817.96 in restitution for her role in healthcare fraud, wire fraud, and theft of government funds. The money judgment represents the proceeds that she obtained as part of her scheme.
Court documents show that between 2008 and 2016 the former owner defrauded the Texas Medicaid program by billing for items and services that had not been provided to the clients of the day care centers.
She also operated a room and board business for Social Security recipients. She charged each boarder $500 to $700 a month to live in a rental property, often placing five to seven boarders to a property. She would not always provide the boarders with their basic needs and at times left them to fend for themselves. She would also refuse to make rent payments on the properties which resulted in forcible evictions of the boarders. She used the money instead for her own personal gain.
In March 2020 she pleaded guilty to one count of healthcare fraud, one count of wire fraud, and one count of theft of government funds.
US Attorney Ashley C. Hoff stated, “Instead of providing necessary services to trusting elderly and disabled Texas citizens, this defendant chose to fleece them of their Medicaid and Social Security benefits for her own selfish gain. We will continue to seek justice on behalf of these vulnerable members of our society and the critical government programs that serve them.”
Issue
The Centers for Medicare & Medicaid Services (CMS) requires that organizations receiving government funds 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 of documentation of services provided and related billing, and the results of the audits should be reported to the compliance and ethics committee and to the governing body. Any discrepancies discovered by the auditing activity should be investigated and rectified immediately.
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, at least annually, and when any issues arise, to include their individual responsibilities to identify and immediately report any concerns that violations may have occurred. Provide periodic retraining to members of the compliance and ethics committee as well. Document that these trainings occurred and file the signed document in each employee’s education file.
- Periodically perform audits to ensure all staff are aware of the expectation that they are to be alert to any compliance and ethics concerns and understand their responsibility to report potential violations immediately to their supervisor, the compliance and ethics officer, or via the anonymous hotline.
