An ineligible Medicaid provider was arrested in Florida for defrauding Medicaid of more than $68,000. According to a Medicaid Fraud Control Unit investigation, the provider had failed to disclose his former felony convictions that precluded Medicaid from accepting the application. Due to the false statement, he received the funds from Medicaid.
The provider had created a business to provide home and community-based services to Medicaid recipients. However, his past criminal record makes him ineligible to be a Medicaid provider. While awaiting sentencing after pleading to and being adjudicated guilty on two felonies in 2017—False, Fictious or Fraudulent Claims against the US and Aggravated Identity Theft—he had enrolled to become a Medicaid provider. On the application, however, he failed to disclose the felony convictions. The false report led to the application being accepted under false pretenses, and he fraudulently received a total of $68,667 from the Medicaid program.
The provider is charged with one count of Medicaid fraud more than $50,000, a first-degree felony. If convicted, he faces up to 30 years in prison and $10,000 in fines.
Florida Attorney General Ashley Moody said, “This suspect willingly falsified his application to become a Medicaid provider and fraudulently received more than $68,000 from the taxpayer-funded program. Deceiving Medicaid for the payout is not only wrong, it’s unlawful, and thanks to the efforts by members of my Medicaid Fraud Control Unit, this man will face justice for his crime.”
Issue:
The US Department of Health and Human Services (HHS) Office of Inspector General (OIG) has the authority to exclude individuals and entities from federally funded healthcare programs for a variety of reasons, including a conviction for Medicare or Medicaid fraud. Those that are excluded can receive no payment from federal healthcare programs for any items or services they furnish, order, or prescribe. OIG maintains a list of all currently excluded individuals and entities called the List of Excluded Individuals/Entities (LEIE). Anyone who hires an individual or entity on the LEIE may be subject to civil monetary penalties (CMP). To avoid CMP liability, healthcare entities should routinely check the list to ensure that new hires and current employees are not on it.
Discussion Points:
- Review your policies and procedures for screening of potential employees to confirm that they are not included on the OIG Exclusion List. In addition, review your policies and procedures for frequency of checking the OIG Exclusion List for all current employees and vendors. Update policies as necessary.
- Train all appropriate staff on the requirement for checking the OIG LEIE link for all new potential hires, current employees, and vendors, and the frequency for repeating the checks. Document that the trainings occurred and file the signed document in each employee’s education file.
- Periodically audit to ensure that all new employees have been confirmed as not being on the OIG LEIE. Also, determine that routine checks are being conducted for current employees to ensure that they have not been added to the OIG Exclusion List. Ensure that a copy of the OIG LEIE screening confirmation is included in each employee or vendor file.
