Pooling Resources

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11941577 - pills and money - business medical background

Pooling resources can help create an efficient working environment by maximizing the use of personnel or equipment. (This decreases operation costs and increases profits.) Two Sumter, South Carolina women thought they’d pool their resources to carry out a Medicaid fraud scheme that involved inflating bills submitted to two government healthcare programs. Nine million dollars later, their pooled resources ultimately sunk, leaving both on the hook for Medicaid fraud.

The two women involved in today’s fraud case served as executives for a business that provided behavioral health and education solutions and autism services for children and young adults. The program started billing for Applied Behavior Analysis (ABA) services in 2003 and by 2015 became the number one biller in the nation. (I’m sure that being the top biller put them on the fraud radar screen.)

One of today’s fraudsters and her business partner sold the autism business to another company for $18 million in 2012. The business partner left when the company sold, but the other partner stayed with the new company. So did another employee who eventually became her partner in crime. The new company employed one of the partners to promote franchises in the Southeast. Her co-conspirator got promoted to be the Senior Vice President of Data Reporting and Analysis. (I bet that job came in handy for doctoring a few bills.)

Court records show that the original company submitted millions of dollars in claims to Medicaid and TRICARE, the healthcare program for uniformed service members, retirees and their families. However, in many cases, autism services were not provided to clients. Today’s article explains that many of the company’s employees were directed to overestimate the time spent providing services to their clients. Company emails served as proof that the company also encouraged employees to bill for time while waiting in client driveways, travelling to and from clients, and also while sitting in restaurants. Bonuses in the form of gift cards and vacations were given if employees met corporate billing goals. (Did these two really think no one would talk?)

Just as these two South Carolinians tried to pool their resources to carry out the Medicaid fraud scheme, several federal and state agencies pooled their resources to catch the co-conspirators. The 53-year-old and the 58-year-old both pleaded guilty to Medicaid fraud. The former company and its new parent company have already repaid the government nearly $9 million in a civil settlement. Both defendants have agreed to serve one year behind bars for stealing about $9 million from Medicaid and TRICARE. (Looks like they’re headed to prison where they will be added into a prison labor pool. They’ll either sink or they’ll swim.)

Today’s “Fraud of the Day” is based on a Department of Justice press release, Sumter Women Convicted of Healthcare Fraud for Over-Charging Government by Millions of Dollars,” released on February 8, 2019.  

Columbia, SC – United States Attorney Sherri A. Lydon announced today that Angela Breitweiser Keith, age 53, and Ann Davis Eldridge, age 58, both of Sumter, South Carolina, pleaded guilty in federal court to one count of false statements to defraud Medicaid.

Evidence presented to the court showed that Keith and Eldridge were executives of the South Carolina Early Autism Project (SCEAP). SCEAP provided behavioral health and education solutions for children and young adults, particularly those diagnosed with autism. SCEAP began providing Applied Behavior Analysis (ABA) services for children with autism in 2003, becoming the number one biller in the country for ABA services by 2015. SCEAP overcharged Medicaid and TRICARE (military-affiliated insurance) millions of dollars by inflating billing records and charging the government for services it did not provide to clients.

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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.