A Little Here, A Little There

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41913416 - medicaid torn newspaper headline on cash

Medicaid is the single largest payer for mental health services in the United States with nearly 12 million visits to U.S. hospital emergency departments. (These individuals had either a mental disorder, a substance abuse problem, or both.) Another shocking statistic from the U.S. Surgeon General claims that 11 percent of youth in the country have been diagnosed with a mental illness. Medicaid combats this growing problem by providing mental health services for vulnerable youth up to age 18 through therapeutic day treatment programs.

Unfortunately, the owner and operator of a day treatment program in North Carolina took advantage of this government-funded service to add a little here and a little there to her bills that were submitted to Medicaid. (She thought Medicaid wouldn’t notice.) Fortunately, the government healthcare program paid attention to the details in the overinflated bills and put a stop to the behavioral health service provider’s Medicaid fraud scheme that bilked the government agency out of nearly $373,000.

Services provided through therapeutic day treatment programs seek to help children and adolescents who suffer from unstable home situations, conduct disorders, adjustment problems, severe mood swings, school problems, rage outbursts, isolation, attention deficit disorder, depression and any other behavioral problems that affect troubled youth. The North Carolina mental health service provider used her certification as a bona fide Medicaid provider to submit false claims stating that she provided services to Medicaid recipients when she did not.

(The behavioral health provider inflated her bills to increase the size of her bank account.)

For more than three years, the woman added units of day treatment services to her bills for certain days and times when she did provide services, but not the amount she claimed. She also claimed that she provided services to patients, when she did not provide any at all. (Sometimes the patients were double booked at another facility where they actually received mental health treatment.) At other times, she billed for services provided even though the facility was closed for snow or for a national holiday. (It’s always the details that trip up fraudsters.) The owner also tried to bill for psychotherapy services as if they had been performed by a licensed medical doctor. (Investigators nipped that claim in the bud after interviewing the doctor who said he did not perform any psychotherapy services.)

The owner of the North Carolina-based mental health services business pleaded guilty to one count of Medicaid fraud for overbilling the government program in the amount of $372,917.74. (The total loss to Medicaid was $337,615.42. Think of all the youth who could have received critical mental health services for that amount of money.) Let’s hope that when this selfish woman is sentenced, she will receive an appropriate sentence along with the requirement to pay restitution in full. (She might receive prison time and be banned from participating as a Medicaid provider.) Whatever the punishment, it’s a given that she will never be able to make up for the lack of quality care she was entrusted to provide.

Today’s “Fraud of the Day” is based on a Department of Justice press release entitled, “Medicaid Fraud Provider Plea,” released March 29, 2019.  

RALEIGH – Robert J. Higdon, Jr., United States Attorney for the Eastern District of North Carolina, announced that in federal court, United States Magistrate Judge Robert B. Jones, Jr. accepted a guilty plea in a health care fraud matter.

ANDREA BOATMAN HALL, now known as, ANDREA MONIQUE PURNELL, 32 years of age, from Sanford N.C., pled guilty to one count of Medicaid Provider Fraud.    

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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.