Deeper Than the Headlines: State Enforcement

As compliance professionals, we tend to focus on large dollar settlements to raise awareness within our organization. These type of events can definitely make some executives pay attention. These settlements also often are announced on a national stage such as the DOJ’s or OIG’s websites in prominent places.

However, one area we tend to neglect is state enforcement. States have increased their enforcement efforts of non-compliance and it’s having an impact. Let’s take a closer look at some examples:

Tennessee

A 51-year old Memphis man was charged with doctor shopping for prescription drugs, using TennCare as payment for the pills. The enforcement was led by Tennessee’s Office of Inspector General (OIG), with the assistance of the county sheriff’s office. The man was charged with five counts of TennCare doctor shopping – which involves using TennCare to visit multiple doctors in a short period of time to obtain prescriptions – in this case, for the painkiller Oxycodone.

The Inspector General, Kim Harmon said, “TennCare benefits are reserved for those truly in need. Using these benefits to fund the opioid epidemic will not be tolerated.” TennCare fraud is a Class D felony punishable by up to four years in prison per charge.

The Tennessee OIG has a hotline were suspected fraud can be reported. They call it the OIG Cash for Tips Program. Tennesseans can get cash rewards for TennCare fraud tips that lead to convictions.

North Carolina

In April, Attorney General Josh Stein announced a settlement with Dr. Carlos J. Privette, D.D.S. over the submission of fraudulent claims to the North Carolina Medicaid program. Claims were submitted on Dr. Privette’s behalf for inhalation of nitrous oxide, performance of full mouth debridements, performance of limited and complete oral evaluations, and the surgical removal of teeth from Medicaid recipients. It was alleged that these services were not medically necessary and/or had no supporting clinical documentation. Dr. Privette will pay the North Carolina Medicaid Program $470,000 in restitution.

The investigation and settlement stemmed from the Medicaid Investigations Division’s continuous focus on Medicaid dental providers within the program who are engaged in fraudulent practices involving a wide variety of services including, but not limited to, dental cleanings, use of nitrous oxide, repetitive restorations on the same tooth, palliative care, and upcoding of patient examinations.

This settlement was obtained with the assistance of the North Carolina Department of Justice, Medicaid Investigations Division and the North Carolina Department of Health and Human Services, Division of Medical Assistance – Clinical Policy and Program Integrity.

New York

Long Island-based pediatrics practice Freed, Kleinberg, Nussbaum, Festa & Kronberg M.D., LLP, doing business as Pediatrics and Adolescent Medicine, as well as current and former partner physicians of the Practice, including Arnold W. Scherz, M.D., Mitchell Kleinberg, M.D., Michael Nussbaum, M.D., Robert Festa, M.D., and Jason Kronberg, D.O. have agreed to pay $750,000 to resolve allegations that they billed the Medicaid Program for services provided by physicians who were not enrolled in the program. The settlement, which resolved government claims under the federal False Claims Act and the New York State False Claims Act, was approved by United States District Judge Joanna Seybert. The Medicaid Fraud Control Unit of the Office of the New York State Attorney General assisted in the investigation.

The government’s investigation revealed that, from July 1, 2004 through December 31, 2010, the practice and partners employed a number of physicians who were not enrolled in the Medicaid Program who provided care to Medicaid patients. Because the physicians were not enrolled in the program, the practice and partners could not seek reimbursement from Medicaid for the services provided by these physicians. The defendants nonetheless did so by submitting requests for payment under the partners’ Medicaid provider identification numbers, thereby misrepresenting the identities of the individuals who were actually providing treatment to the practice’s pediatric Medicaid beneficiaries. This improper billing practice occurred at many of the practice’s Long Island locations, including facilities in Holbrook, Port Jefferson, Shirley and Wading River.

The allegations were brought to the government’s attention through the filing of a complaint pursuant to the qui tam provisions of the False Claims Act. Under the Act, private citizens can bring suit on behalf of the United States and share in any recovery.

Though national headlines are important to stay on top of, don’t forget to regularly review the various state enforcement reports as well for an effective compliance program.

Questions or Comments?