ILNews

Specialized units target Medicare, Medicaid swindlers in Indiana

Back to TopCommentsE-mailPrint

Inside an unmarked building in a nondescript office park in Castleton is a burgeoning, multi-million-dollar legal enterprise. Its mission: cracking down on Medicaid fraud.

“This work is really a niche area; there are not a lot of people involved in it,” said Deputy Attorney General Allen Pope, who heads the 53-member Indiana Medicaid Fraud Control Unit’s 10 offices around the state that operate under the direction of the attorney general’s office. “Just the acronyms you have to learn is daunting.”

fraud-main-15col.jpg Assistant U.S. attorney Bradley Shepard in the Southern District of Indiana oversaw fraud cases that recovered more than $3 million in tax dollars in 2012. (IL Photo/ Dave Stafford)

Complex investigations that involve an array of agencies and local, state and federal law enforcement also must delicately balance patient care. Nevertheless, sums recovered from providers in Medicaid and Medicare fraud investigations have soared in recent years. For instance:

For 2012, through early December, the Indiana MFCU recovered more than $52 million, Pope said. That’s a record that compares to about $4 million when Pope came to the agency a decade ago.

According to the U.S. Department of Health and Human Services, the government has recovered a record $10.7 billion from Medicare and Medicaid fraud in the last three years.

Health care fraud cases can come from anywhere. Bradley Shepard, assistant U.S. attorney for the Southern District of Indiana, recalls a case that originated with a quality-control representative’s follow-up call to a Medicaid patient in a routine survey about care.

When the patient was unfamiliar with prescription medications for which Medicaid had been billed in the patient’s name, it raised suspicions that ultimately led to federal prison for Terre Haute pharmacist John D. Love. He was sentenced in October 2011 to 51 months for billing Medicaid more than $3.5 million for prescriptions that were never given to patients.

Love had billed for prescriptions that far exceeded the quantities his pharmacy received, investigators learned.

“I just find it very offensive,” Shepard said, discussing why he is so motivated to fight health care fraud. “For people to have their greed prey upon a system that’s based on purely good intentions, those individuals are due all the punishment they have coming to them.

“And I like the puzzle aspect of it,” he said.

For Medicaid program administrators at the state Family and Social Services Administration, the puzzle pieces come from analysis of billings using nearly three dozen algorithms designed to ferret out red flags in the multitude of individual claims filed for payment, explained audit manager Kim Forrest. A simple algorithm, for example, identifies claims for services provided after a patient’s date of death.

“We try to prevent money from going out the door, because it’s much harder to get it back once it’s gone out the door,” Forrest said.

Impact on patient care is a consideration, though. “We do that evaluation every time we make a payment decision,” she said.

FSSA takes charge of cases in which waste is found, and that can be for instances such as billing twice on the same day for payment of services allowed just once, program officials said. “Most of what we find is not fraud, it’s waste and abuse,” said Kristina Moorhead, deputy manager for program integrity for Medicaid planning at FSSA.

But the new health care law puts an emphasis on enforcement and puts the onus on the agency.

“The Affordable Care Act has done a few things – one is that we are required to submit credible allegations of fraud to the Medicaid Fraud Control Unit,” said Moorhead. Those can be from patient tips, those developed internally, or from whistleblowers.

What constitutes a “credible allegation” isn’t defined. “It’s a pretty light standard our office has to meet,” said Brandon Shirley, an attorney with the FSSA Office of General Counsel.

The Affordable Care Act also increased provider enrollment standards, requiring site visits for new providers and in other situations. “Between 20 and 30 providers were not enrolled in the past calendar year due to onsite visits,” Moorhead said.

A couple of times a month, FSSA officials who oversee Medicaid meet with MFCU representatives and other law enforcement to talk about possible cases and share information, including those credible allegations of fraud the agency is compelled to disclose.

U.S. Attorney for the Northern District of Indiana David Capp said the information sharing is invaluable. In his office, Medicaid and Medicare fraud cases are assigned to some of the most experienced attorneys.

Capp said health care fraud cases “have received substantial attention from us for quite some time. They’re high-priority prosecutions, and we work hand-in-hand with Attorney General (Greg) Zoeller on many of them, and I can’t say enough about the attorney general’s office. They’ve been instrumental in a number of prosecutions.”

The Northern District in 2012 won Medicare and Medicaid fraud judgments of $8.1 million, compared with less than $1.5 million a year earlier, according to spokeswoman Mary Hatton. Major convictions came in U.S.A. v. Human Services Transport Provider Inc., 3:11-CR-5. The Gary-based ambulance service defrauded Medicaid of $1.9 million, according to two guilty pleas in the case, and restitution of close to $2.5 million was ordered.

In that case, the ambulance company billed for services that weren’t provided, inflated mileage claims, and conspired to kick back some of the fraudulent revenue to another provider.

pope Pope

Often, people identify fraud with the anticipation that they might share in the reward for doing so. “Ninety percent of the people are whistleblowers,” Pope said of those who initiate MFCU investigations.

Such cases have been enabled by Indiana’s False Claims Act, I.C. 5-11-5.5. Passed in 2005, the act allows qui tam claims in which whistleblowers may be eligible to collect 10 to 30 percent of tax money recovered by the government. “The truth is at this time we have multiple whistleblowers in the cases that get settled,” Pope said.

The dollars coming in this year are the result of investigations that began years earlier, he said. Whistleblower cases can take as long as eight years to conclude because of the amount of discovery required and the complexity of the cases.

Several multi-million-dollar settlements of late involve “off-label” marketing of pharmaceuticals – medications sold for treatments other than those the drugs have been approved for by the Food and Drug Administration, Pope said. Whistleblowers were key to those cases.

One of the most prevalent fraud schemes Shepard described is “upcoding” – vendors billing for procedures, products or services costlier than those provided. But he said it’s not easy to get jury convictions based on billing-code patterns found in reams of documents in Bankers Boxes worth of evidence.

“Sometimes the investigation is a lot easier than coming up with a compelling way to take it to the jury and make it make sense,” Shepard said. Nonetheless, he’s personally overseen cases in 2012 that resulted in recovery of more than $3 million in tax dollars. The total of recovery in Medicaid and Medicare fraud cases for all of the Southern District was not available.

For all the information sharing that’s led to a spike in recoveries and criminal penalties, Pope said there’s more that he and others in the field would like to be able to do. Currently, Medicaid Fraud Control Units are prohibited from independent claims analysis without referrals from the administrative agency – in Indiana’s case, FSSA.

“For 10 years it’s been a matter of discussion (nationally among MFCU officials) because it does make sense” to have greater independent investigative authority, Pope said. “When we have a particular suspected pattern of fraud, we’d like to have the ability to do that.”•

ADVERTISEMENT

Post a comment to this story

COMMENTS POLICY
We reserve the right to remove any post that we feel is obscene, profane, vulgar, racist, sexually explicit, abusive, or hateful.
 
You are legally responsible for what you post and your anonymity is not guaranteed.
 
Posts that insult, defame, threaten, harass or abuse other readers or people mentioned in Indiana Lawyer editorial content are also subject to removal. Please respect the privacy of individuals and refrain from posting personal information.
 
No solicitations, spamming or advertisements are allowed. Readers may post links to other informational websites that are relevant to the topic at hand, but please do not link to objectionable material.
 
We may remove messages that are unrelated to the topic, encourage illegal activity, use all capital letters or are unreadable.
 

Messages that are flagged by readers as objectionable will be reviewed and may or may not be removed. Please do not flag a post simply because you disagree with it.

Sponsored by

facebook - twitter on Facebook & Twitter

Indiana State Bar Association

Indianapolis Bar Association

Evansville Bar Association

Allen County Bar Association

Indiana Lawyer on Facebook

facebook
ADVERTISEMENT
Subscribe to Indiana Lawyer
  1. Am I the only one who sees that the City is essentially giving away the MSA site AND giving millions to build new buildings on the site when this site would be the perfect place for the Justice Complex? Across from City-County, check; keeping it centrally located, check, etc. It's my understanding that the GM site must be purchased by the City from Motors Liquidation Company. STOP WASTING WHAT WE ALREADY HAVE AND OUR TAX DOLLARS! The Ballard Administration has not been known for it's common sense...never voted for him and never will!

  2. This guy sounds like the classic molester/manipulator.

  3. Louis D. Brandeis was born in 1856. At 9 years of age it would have been 1865. The Brandeis family did not own slaves. My source Louis D. Brandeis: A Life, by Melvin L. Urofsky.

  4. My name is Matthew Lucas Major, I recently went through a jury trial in Bloomington , In. It was the week of Feb 19-21. Although I have been incarcerated since August 5, 2014. The reason I 'am writing to you sir is on the 21 of February the jury came in with a very excessive and wrongful verdict of guilty on 6 child molesting charges against my daughter who was 9 at the time I was accused. I also had 2 other Felonies one of Intimidation and 1 of Sexual Vicarious Gratification. Judge Marc Kellam on the second day of trial gave me a not guilty on those 2 felonies. The jury was sent out during that time and when brought back Judge Kellam told them to not concern themselves with the 2 Felonies that he ruled on them. They were told to not let evidence they had already heard influence there verdicts. I never in my life touched any child sexually and definitely not with my own daughter. When I was arrested Detective Shawn Karr told me I would be convicted guilty just on my daughters word even without evidence. That's just what happened. my public defender did me so wrong he never once proved to the court and jury all the lies the child told, and Jeremy Noel my public defender could of proven the lies easily. The stories in Serenity's depositions and Forensic interview changed and were not consistent as Prosecutor Darcie Fawcett claimed they were. Yet my attorney never mentioned that. The facts that the child accused me of full penetration in her vagina and rectum was proven lies. Doctor Roberta Hibbard of Riley hospital in Indianapolis confirmed Serenity's hymen intact, no scars, no tearing, no signs of rape to her. Yet my attorney didn't use that knowledge . the DNA was all in my favor. I tell you I will spend my entire life in prison going through rape and beatings etc. even Judge Kellam abused his authority by telling the jurors to listen and believe what the prosecutors side in evidence like my daughters testimony. In one interview with the detectives my daughter got flustered with her mom and said on camera " I'm saying what you told me to mom"!! Yet Mr. Noel said nor did anything to even resemble a defense attorney. Judge Kellam allowed edited version of a taped conversation between the child and her mother. Also Judge Kellam allowed the Prosecutor too bring in to my case a knife found under my seat, the knife wasn't part of my case. She was allowed by my attorney and the judge to put a huge picture of it on the screen and huge picture of my naked privates in a full courtroom and open court. Ms. Fawcett says to jury see how easy Mr. Major could reach the knife and cut his Childs throat. Even though I had no weapons charge against these cases. This gave the jurors prejudice thought against me thinking I threatened her with that knife and how scared she would of been knowing i could get it and kill her. On my sentencing court March 19, 2014 my public defender told Judge Kellam he wish to resign from being my attorney and wished for the court to give me outside council to file a error to trial or appeal. We were denied. Now after openly knowing my public defender don't want to represent me he has to. Well when as parents we make our kids clean a room when they really don't wish to, well the child will but don't mean she will do a good job, that's where I'm at with Mr. Noel. please dont ignore mine and my families pleas for your help . we have all the legal proof you could need to prove Im innocent. Please dont make my spend years in prison innocent when you can fix this wrong. Im not saying Im a perfect man or that I was a perfect dad to my 2 children none of us are. Ive made some bad choices in life and I paid for them. But I didnt ever touch or rape my daughter . I love my children with all my heart. And now through needing attention and a ex-wife who told my granny several times she wish she could put me in prison to get me out of their lives. Well my ex finally accomplished her goal. Sad part is she is destroying our daughter with all this horrific lies and things she taught my daughter to say. My daughter will need therapist to ever hope for a chance of a normal life after what she had done to her by her mom and their side of the family. My daughter told everyone even on stand she had a dream months before i supposedly molested her in this dream I was molesting her and when I finally did it matched her dream perfectly. She admitted to watching movies about little girls being molested and watching U-Tube videos about child molesting all before it happened supposedly to her. Doesn't that sound very unusual that a non molested 9 yr old would need to know so much about being molested? The only reason I could think a 9 year old would need so much information is to be prepared to know what to say and be able to say how it felt what took place etc.. So when questioned by authorities she would be prepared. And there again sir if a parent is pre grooming a 9 year old child she would need intimate details . Like telling her daughter about a couple moles on my private area. The child admitted to sneaking my cell and looking many many times at nudes of me and my girlfriend even one where my penis was entering my girlfriends vagina. In that picture my moles are obvious. Yet when prosecutor showed everyone in court my privates and pictures of the moles she said the only way the child would know about them is if she saw them for herself. My attorney once again said nothing about the pictures my child saw. Or could a ex-wife be able to describe my moles to help her case against getting rid of me? I beg you help me. This is my very existence. Ive lost everything , a good job, a wonderful girlfriend, my freedom, but worse thing Ive lost is my children. They were my reason to get up every morning and strive to be better. The wonderful bond I had with my Serenity is gone. After this I would be afraid to even hug her for fear of what next can they do to me. I'm not afraid to tell you I sit here in this cell and try to hold back my tears. Everyone knows you cant show weakness in prison. My life has already been threatened here at Wabash Valley Prison. After only 3 days of arrival. I was tricked into signing a waiver now Im in G Block General Population with 6 child molesting felony charges. Mrs. Hart as a 18 year old I almost died hooked to machines in hospital almost 1 month and now I know that fear was childish compared to this . I cant help but put emotions in this, after all Mrs. Hart Im human and God help Me I never been more afraid in my life. I didnt hurt my little girl I didnt touch her sexually. As much as it shreds me and fills my mind what Im facing I worry more about my mom and granny because of their great love for me mam they are suffering so deeply. I aint done this things but my loved ones suffering right along beside me and If you take my case you will be in essence freeing them also. I sent momma this letter and asked her to email it to you. I'm scared I have been done so unjustly by our legal system and I need you to fix this and give me freedom. I ask you please don't just ignore my pleas. Here in America its nice to be able to trust our legal justice system, well they destroyed my and my loved ones trust in our justice system . And I'm trusting in You !!! My entire family is suffering this nightmare with me. My 77 year old granny had a stroke and isn't doing so well. My single mother that raised 3 kids alone is dying from Lupus and since my arrest has stayed so sick and weary. Our lives torn to peices by a government I was taught I could trust in. my momma has tried so many innocent project and wrongfully accused and cant get anywhere. please please help me. A quote from the late Nelson Mandela: To be free is not merely to cast off ones chains, But to live in a way that respects and enhances The Freedom Of Others. I have Faith in you and your clinic to cast my chains off and give me freedom I do deserve as a wrongfully accused Man, son, brother, father, friend. Matthew Major DOC# 246179 Cause # : 53c02-1308-FA-000779 God Bless you. Please contact me with your decision so I know you made a life changing decision for me , just please at least write me so I know you care enough about your citizens to respond to cries for your help. You can speak openly with my mother Charlotte Spain (828) 476-0406: 71 Lakeview Dr. Canton, NC 28716 Thank You Matthew Major I know yall get thousands of request and inmates claiming innocence, and each person who are innocent deserve to have organizations like yours willing to fight for them and I give yall so much Thanks and I thank God everyday yall are out there caring enough to help free the innocents. Since discovering firsthand how easily lives and families can be destroyed by Poor Defense attorneys not doing their job . And Prosecutors allowed to do as they please in court

  5. Frankly, it is tragic that you are even considering going to an expensive, unaccredited "law school." It is extremely difficult to get a job with a degree from a real school. If you are going to make the investment of time, money, and tears into law school, it should not be to a place that won't actually enable you to practice law when you graduate.

ADVERTISEMENT