The Medicaid Money Pot

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Physiotherapist giving physical therapy to senior male patient in clinic

Medicaid Fraud Control Units (MFCU) investigate and prosecute provider fraud, as well as elder abuse and neglect of our nation’s most vulnerable citizens. They go after criminals, like today’s fraudster, who submitted bogus bills to Medicaid for services she did not provide. The woman, who was from Las Vegas, Nevada, used her behavioral health agency to knowingly commit Medicaid fraud through the preparation and submission of fake documentation to the federal government healthcare program.

The Department of Health and Human Services partners with states to administer Medicaid, the primary source of health coverage for around 72 million Americans. Medicaid covers low-income individuals, children and families who don’t have access to other health insurance. It also provides long-term care services and support to seniors and individuals of all ages with disabilities. Recent statistics show that 10.1 percent or $36.7 billion of the healthcare program’s payments were improper. (That’s a lot of money.)

In 2016, Medicaid spending was $3.4 billion in the State of Nevada. Today’s criminal dipped her hand into the taxpayer funded money pot and collected more than $50,000 in Medicaid funds she did not deserve over a two-year period.

The Nevada MFCU received notification that the owner of the behavioral health agency was submitting claims for services that her company did not provide. (Maybe an employee ratted on her.) She went to great lengths to carry out the scheme including creating false documentation with progress notes concerning the alleged services provided to her Medicaid patients. (Although, there were multiple problems with her claims.)

 The fraudster’s victims never received the services documented by the business owner. On top of that, she neglected to substantiate the claims by providing the actual dates, times and services she allegedly provided to her Medicaid patients. (No wonder her claims were flagged.)

The 50-year-old woman from Las Vegas was convicted of Medicaid fraud and sentenced to serve a term of 12 – 48 years in prison, suspended. (Now that’s lucky.) She also must pay back $50,324 in restitution. (On the other hand, that was not so lucky, and a justly deserved sentence.)

Each year, MFCUs recover millions of dollars from fraudulent claims. (Just in 2016, more than $1.8 B was recovered as a result of the efforts of 1,965 staff members across 49 states and the District of Columbia.) The successful prosecution and conviction of this Medicaid provider should serve as a reminder to other business owners who are thinking of stealing money reserved for Medicaid recipients in need.

Today’s “Fraud of the Day” is based on an article entitled, “Vegas Healthcare Worker Sentenced on Medicaid Fraud,” posted at lasvegas.cbslocal.com on October 17, 2017.

LAS VEGAS (KXNT) – On Tuesday, Nevada Attorney General Adam Laxalt announced that 50- year-old Shawnnyce Dawson of Las Vegas, was sentenced for submitting false claims to Nevada Medicaid. The fraud happened between January 2013 and March 2015.

Eight Judicial Court Judge Jennifer Togliatti sentenced Dawson to one felony count of submitting false claims. As a part of the sentence, Dawson was ordered to serve a term of 12-48 months in prison, suspended, and to pay restitution of $50,324.

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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.