Fraud is a Huge Gamble

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41913416 - medicaid torn newspaper headline on cash

The Centers for Medicare & Medicaid Services (CMS) reports that the Medicaid improper payment rate reached 10.5 percent, or $61.2 billion in 2016. While there are a variety of ways to commit Medicaid fraud, today’s “Fraud of the Day” article takes a look at how six St. Louis, Missouri home healthcare workers and patients purportedly took advantage of the government healthcare benefits program by submitting false timesheets claiming they provided or received personal care services when they were either working other jobs, on vacation or gambling.

The first case involves a 58-year-old woman, who was supposed to be receiving assistance from her 75-year-old male care giver at her home. Both signed off on Medicaid timesheets showing that she received care in her home even though she was actually taking a cruise and vacationing in New Orleans at the time.

The second case involves two women with the same last name. (Perhaps they were related.) A 46-year-old woman and a 28-year-old woman allegedly made four false claims to Medicaid stating that the older woman was receiving Medicaid-funded home care, when she was actually gambling at a local casino, or working as a caregiver herself. (That’s an interesting twist. She claimed to be receiving care while also giving care. That was a big gamble to take.)

The last case mentioned in the press release involves a 50-year-old patient and a 27-year-old caregiver. Both were supposedly working at other jobs during the times in which they were falsely claiming to be receiving or providing home healthcare at the patient’s home. (The caregiver was allegedly in New Jersey and California on some of the days that he and the patient claimed home healthcare services had been provided.) In addition, the patient had previously filed for Social Security disability payments, but neglected to report that she had received income from her jobs. (This obviously makes her ineligible to receive government benefits.)

Home healthcare is supposed to be an alternative to skilled nursing home facilities that allows the person who is receiving care to remain in the comfort of their own home. (It also helps save tax dollars, because it is less expensive.) When fraudsters steal money from the government healthcare system, they are also robbing Medicaid beneficiaries of services they qualify for and deserve.

While these six Missouri home healthcare workers and patients have been charged with Medicaid fraud, they remain innocent until proven guilty. If convicted, they face a maximum of five years in prison and fines up to $250,000. Theft of government property could deliver a maximum sentence of ten years in prison and fines up to $250,000. Whatever happens next, it’s safe to assume that they took a huge gamble by trying get away with falsifying their time cards. Now it’s time to hear what the court has to say.

Today’s “Fraud of the Day” is based on a Department of Justice press release entitled, Six Home Healthcare Workers and Patients Charged with Billing Medicaid while Working other Jobs, Going on a Cruise, and Gamblingreleased on April 4, 2017.

St. Louis, MO – Six area home healthcare workers and patients were charged with making false statements to Medicaid regarding home healthcare services that were neither received nor provided. All of the Indictments involve allegations that the defendants made false statements in Medicaid timesheets that certain patients and workers provided or received personal care services (e.g. grooming, cleaning, feeding, and medication assistance) in the home setting during certain dates and times when, in reality, the patients or workers were actually somewhere else.

Regina Brown, 58, and James Smith, 75, both of St. Louis, Missouri, were charged by Indictment with three felony counts making false statements to Medicaid that Brown received Medicaid-funded home health care from Smith at Brown’s home. In reality, Brown was actually vacationing in New Orleans and on a cruise ship during the dates indicated on their Medicaid timesheets.

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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.