Loud and Clear

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65037362 - healthcare cost concept with calculator and medical bill

The False Claims Act (FCA) came about in 1863 when Congress became concerned that suppliers serving the Union Army during the Civil War were defrauding the Army. At that time, the FCA required any person who knowingly submitted false claims to the government to pay $2,000 for each one. (The ramifications for carrying out such an illegal deed have changed quite a bit since then and are now at between $5,500 and $11,000 per falsified claim.) A Jacksonville, Florida business that provided treatment to autistic children recently avoided a healthcare fraud conviction when they agreed to pay $360,000 to resolve an FCA allegation. The provider allegedly submitted false claims to TRICARE, the healthcare program for active and retired military personnel and their dependents.

Just to provide some background for this case, as of 2014, the Centers for Disease Control and Prevention (CDC) reports that one in 59 children were identified with autism spectrum disorder (ASD), up from one in 150 in 2000. The organization also reports that the total costs per year for children with ASD in the United States is between $11.5 billion and $60.9 billion. (This economic burden includes direct and in-direct costs such as medical care, special education and even lost parental productivity.) The annual cost for medical expenditures associated with a child or adolescent with ASD is between $4,110 and $6,200. (The subject of today’s fraud article took advantage of a government healthcare program by misrepresenting the services they provided to their patients.)

The Jacksonville-based business billed TRICARE for Applied Behavioral Analysis (ABA) therapy services allegedly provided to children with Autism. (This intensive behavioral treatment helps patients to increase language and communication skills, improve attention, focus, social skills, memory and academics and decrease problem behaviors.) A big problem arose when the organization was not honest about the services provided or the people providing those services. (Then, there was the issue of the lack of documentation for said services and the altered medical records to consider.)

The article doesn’t state who blew the whistle on this deceptive provider, but it could have been a bunch of disgruntled parents or a very astute claims adjuster for TRICARE. The bottom line is that the ABA provider heard the whistle loud and clear and paid $360,000 to resolve an FCA allegation regarding falsified claims. (Just as an aside, anyone who blows the whistle on fraud can receive between 15 and 30 percent of the amount recovered by the government. That’s quite an incentive to report any suspicions of fraud.)

This case is a good example of why it is very important to review insurance statements and provider bills to make sure that you received the services by a legitimate provider as claimed. This Jacksonville, Florida provider and its senior management agreed to pay back TRICARE the $360,000 of charges in dispute, avoiding a healthcare fraud conviction. That was definitely the right thing to do when it comes to protecting children with special needs who require vital services.

Today’s “Fraud of the Day” is based on a Department of Justice press release, “East Coast Stepping Stones, Inc., A Jacksonville-Based Provider For Children With Autism, Pays The United States $360,000 To Settle Allegations Of Fraud,” released on January 28, 2019.  

Jacksonville, FL– United States Attorney Maria Chapa Lopez announced today that East Coast Stepping Stones, Inc. (“ECSS”) has paid the United States $360,000 to resolve a False Claims Act allegation that it submitted false claims to the TRICARE program for therapy services for children with autism. ECSS is a Jacksonville-based provider of intensive behavioral treatment to children with autism, known as Applied Behavioral Analysis (“ABA”) therapy. TRICARE is the federal health insurance program for active and retired military members and their families.

The settlement announced today resolves allegations that ECSS billed TRICARE for ABA therapy services for children with autism that misrepresented the services provided and who had provided them. ECSS also failed to document services as required, and fabricated and altered medical records. ECSS and its senior leadership— Amantha Massey-McLaughlin, Kevin McLaughlin, and Susan Quinn—have agreed to pay $360,000 in an ability-to-pay settlement.

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Larry Benson
Larry Benson is currently the Director of Strategic Alliances for Revenue Discovery and Recovery at LexisNexis Risk Solutions. In this role, Benson is responsible for developing partnerships for the tax and revenue and child support enforcement verticals. He focuses on embedded companies that have a need for third-party analytics to enhance their current offerings.