New Jersey Sentences Medicaid Fraud

Essex County Pharmacy Owner Sentenced in Medicaid Fraud Investigation
Medicaid program billed for expensive HIV/AIDS prescriptions never dispensed


TRENTON – Attorney General Paula T. Dow and Criminal Justice Director Stephen J. Taylor announced that the owner of a Newark pharmacy was sentenced today in connection with an investigation into pharmacy owners and employees who bought completed prescription forms for HIV/AIDS drugs from indigent patients so Medicaid could be billed for drugs that were never actually dispensed.

According to Acting Insurance Fraud Prosecutor Riza Dagli, Nwala Gabriel, 49, of Piscataway, was sentenced to three years of probation by Superior Court Judge Michael A. Petrolle in Essex County. Judge Petrolle also ordered Gabriel to pay $178,272 in fines and restitution and to serve 150 hours of community service. Gabriel will be excluded from the Medicaid program for three years. He must surrender his license to practice pharmacy for a minimum period of three years or until he successfully completes all terms of his criminal sentence.

The sentence was based on Gabriel’s guilty plea to Medicaid fraud. The charge was contained in a state grand jury indictment obtained by the Office of the Insurance Fraud Prosecutor’s Medicaid Fraud Control Unit on Oct. 26, 2009.

In pleading guilty on Feb. 23, Gabriel, the owner of Harrison Pharmacy on Martin Luther King Boulevard in Newark, admitted that he fraudulently billed Medicaid for prescription drugs that were never dispensed to the Medicaid beneficiaries.

Deputy Attorneys General Sherry Wilson and Debra Conrad represented the Office of the Insurance Fraud Prosecutor at today’s sentencing.

Gabriel was charged as a result of Operation PharmScam, an ongoing investigation targeting Medicaid fraud that began in 2008 and has been conducted by OIFP’s Medicaid Fraud Control Unit, the Jersey City Police Department and the U.S. Food and Drug Administration’s Office of Criminal Investigations.

On Oct. 26, 2009, a total of 11 defendants, including Gabriel, were indicted as a result of the investigation into pharmacies that were buying prescriptions from patients and billing the Medicaid Program for medicines that were never dispensed. A full list of defendants charged is in the Oct. 26, 2009 press release at www.njpublicsafety.com.

On Jan. 19, two technicians at Pharmacy of America who were indicted, Jannah Rasheedah Amatul Muid and Alicia Stephens, pleaded guilty to Medicaid fraud. On March 8, Muid and Stephens were sentenced to three years probation, ordered to pay a $1,000 civil fine and were barred from participating in the Medicaid Program for a period of five years. Muid was ordered to perform 150 hours of community service, while Stephens was ordered to perform 100 hours community service. On the same day, Shivonne Forde, another Pharmacy of America technician, pleaded guilty to third-degree possession with intent to distribute prescription legend drugs. Forde’s sentencing is scheduled for June 3.

The investigation has been conducted for the Medicaid Fraud Control Unit by Detective Danielle Han, Detective Joseph Jaruszewski, Detective Jacqueline Latty, Detective Kevin Gannon, Sgt. Fred Weidman and Sgt. James Wrightson. Deputy Attorneys General Sherry Wilson and Debra Conrad are leading the prosecutions, with assistance from Deputy Attorney General Erik Daab, who is Deputy Chief of the Medicaid Fraud Control Unit, and Deputy Attorneys General William Hoyman, Cynthia Vazquez, Linda Rinaldi and Carol Stanton Meier.

The Medicaid program, which is funded by the state and federal governments, provides health care services and prescription drugs to persons who may not otherwise be able to afford such services and medicines. The State of New Jersey administers the Medicaid program through the Division of Medical Assistance and Health Services and through the Office of the Insurance Fraud Prosecutor’s Medicaid Fraud Control Unit, which investigates both criminal and civil Medicaid fraud and abuse in that program.

Anyone with information about fraud or abuse involving the Medicaid program or Medicaid providers is urged to call the Medicaid Fraud Control Unit toll free at 1-877-55-FRAUD or report it online at www.NJInsuranceFraud.org. All information received will remain confidential.

How To Catch A Medicaid Fraudfeasor: A Primer

As those of you loyal followers who may already know, and for those who wish to learn,
The U.S. Department of Health and Human Services Office of Inspector General (DHHS OIG) in partnership with the U.S. Department of Justice Attorney General (DOJ AG) has created the Health Care Fraud Enforcement Task Force (H.E.A.T.) to stop Medicare and Medicaid Fraud.

The purpose of H.E.A.T. is to end the annual billions of dollars in fraud, waste and abuse of taxpayer dollars, because, obviously, the states Medicaid Fraud Control Units just were not doing what they were suppose to be doing, and that is stopping Medicare and Medicaid Fraud.

In addition, it seems that the DHHS OIG and the DOJ AG have publicly confessed, with its creation of H.E.A.T., to have been snoring and drooling at the helm as the overseeing admirals of the states Medicaid Fraud Control Units.

But now, since the act of contrition, we need to move forward and get these Strike Forces up and operating, quickly!

Below, is the precursor of my primer on "How To Catch a Medicaid Fraudfeasor."
(Fraudfeasor means simply, "One who commits fraud.")

The following is taken directly from the National Association of Medicaid Fraud Control Units Frequently Asked Questions:

1. What is a Medicaid Fraud Control Unit?

A Medicaid Fraud Control Unit (“Unit” or “MFCU”) is a single identifiable entity of state government, annually certified by the Secretary of the U.S. Department of Health and Human Services. The Unit has either statewide criminal prosecution authority or formal procedures for referring cases to local prosecutorial authorities with respect to the detection, investigation and prosecution of suspected criminal violations of the Medicaid program. See 42 U.S.C. §1396b(q). There are 50 state MFCUs. 43 are currently located in the office of the state Attorney General. Connecticut, D.C., Georgia, Illinois, Iowa, Tennessee and West Virginia have Units which are in other departments of state government. North Dakota received a waiver from the federal government and does not have a Unit.

Since I enjoy using Michigan as my case study, let us begin to examine the deficiencies in this description.

Michigan has a Medicaid Fraud Unit located in the Office of Attorney General, Child and Family Services Bureau, called the Health Care Fraud Division. The duties and responsibilities are to the Department of Human Services through "Medicaid fraud and patient abuse investigations, prosecutions, civil Medicaid recoveries, and vulnerable adult matters."

What is wrong with this picture? The Health Care Fraud Division does not touch "child matters." So, why is this?

Well, the proper response is that the Michigan Office of Attorney General does deal with "child matters." As a matter of fact, there is an entire division dedicated to "child matters" called the Children and Youth Services Division. Oddly enough, the Division only deals with child matters in Wayne County by making the county the only one in the state whereby the Attorney General prosecutes child abuse and neglect matters.

So, how is it that the Attorney General can investigate fraud and protect vulnerable children when the Attorney General is the one advocating for the ones who are the fraudfeasors?

The answer may not be a clear as one would imagine.

At first glance, you see an inherent conflict of interest; this being the Attorney General would have to investigate and advocate, prosecute and defend, or basically, snitch on himself. This is only the first layer.

The next layer is a question of an independent and autonomous authority to investigate and refer Medicaid Fraud for prosecution and recovery. This would be the co-location of authority of the Office of Children's Ombudsman (OCO). The office is, or was, situated in the Department of Management of Budget. Targeted Case Management is a Medicaid funded program for foster care, adoption and juvenile justice. The OCO has the formal authority, through statute and autonomy, to investigate complaints dealing with children in these Medicaid programs, and to make referrals to the counties prosecutors or Attorney General when Medicaid Fraud is suspected. OCO has never made one referral of suspected Medicaid Fraud for prosecution and recovery.

Unfortunately, the DHHS Secretary has certified Michigan's Medicaid Fraud Unit, even though its functions of controlling Medicaid Fraud in child welfare programs are non-existent.

2. Must each state have a MFCU?

Under federal law, each state must have a Unit unless the state demonstrates to the satisfaction of the Secretary of the Department of Health and Human Services that a Unit would not be cost effective because minimal fraud exists in the state's Medicaid program and Medicaid beneficiaries will be protected from abuse and neglect.

3. What is the jurisdiction of a MFCU?

A Unit's function is to conduct a statewide program for the investigation and prosecution of health care providers who defraud the Medicaid program. In addition, a Unit reviews complaints of abuse or neglect against patients in health care facilities receiving Medicaid funding and may review complaints of the misappropriation of patients' private funds in these facilities. The Unit is also charged with investigating fraud in the administration of the Medicaid program. The Ticket to Work and Work Incentives Improvement Act of 1999 authorizes the Units, with the approval of the Inspector General of the relevant federal agency, to investigate fraud in other federally-funded health care programs, if the case is primarily related to Medicaid. This section also authorizes the Units, on an optional basis, to investigate and prosecute resident abuse or neglect in non-Medicaid board and care facilities.

In Michigan, investigations of child resident abuse or neglect falls under the jurisdiction of the Department of Human Services (DHS), the same entity that is procures contracts of residential programs. The Bureau of Children and Adult Licensing (f.k.a. Office of Children and Adult Licensing and was located, independenty, in the Department of Energy, Labor and Growth) has the statutory authority to investigate and protect vulnerable children in receiving care from a licensed facility, particularly under the auspices of the state. This small group of investigators generate findings reports, but are not obligated to refer suspected and substantiated matters of Medicaid Fraud to any law enforcement authority.

4. How are MFCUs funded?

MFCUs receive annual grants (Federal Financial Participation or "FFP") from the U.S. Department of Health and Human Services. Grant amounts must be matched with state funding. Initially, a Unit receives federal funding at a 90 percent level. After its first three years, the FFP is reduced to 75 percent.

The FFP is reduced because the states MFCU are to become sustainable in the prosecution and recovery of Medicaid Fraud. Michigan has finally effectuated (rather semi-effective because there is very little civil incentive for individual referrals of Medicaid Fraud) and enhanced Medicaid False Claims Act. The point of this being the state will aggressively target and capture the recovery funds of Medicaid Fraud. By doing so, the state is allowed to recovery %10 of the FFP.

Alas, in the realms of child welfare, this has never been done.


5. What are the limitations on federal financial participation?

Federal financial participation is authorized for full-time attorneys, investigators and auditors involved in the investigation and prosecution of matters within the jurisdiction of a Unit. Full-time employees are required to be hired to perform full-time duty intended to last at least a year. Federal grant money may also be used for part-time support staff but only to the extent that these part-time employees participate in work activities that further the jurisdictional duties of the Unit. Finally, FFP is available to the Unit's parent agency to cover all indirect costs associated with the operation of the Unit.

Here is a really fun little item: "If the OCO is the co-location of authority to investigate Medicaid Fraud, matters well within the jurisdiction of the Medicaid Fraud Unit, and it never refers suspected and/or substantiated Medicaid Fraud, is FFP being used, and if it is, is being used to cover the state share of the percentage formula?


6. What are MFCU minimal staffing levels?

A Unit is intended to operate using a "strike force" concept of investigators, auditors and attorneys working together full-time to develop Medicaid fraud investigations and prosecutions. The staff of the Unit must include attorneys experienced in the investigation and prosecution of civil fraud or criminal cases, auditors capable of supervising the review of financial records, and investigators with substantial experience in commercial or financial investigations. If a Unit lacks direct prosecutorial authority, it must have a formalized procedure in place for referring cases to the appropriate prosecutorial authority.


Due to the fact that Michigan Medicaid Fraud Unit has never engaged in "strike force" operations, especially in child welfare, H.E.A.T. has stepped up to the plate.

7. What is the extent of federal oversight over a MFCU?

Each Unit operates under the administrative oversight of the Inspector General of the U.S. Department of Health and Human Services and must be recertified annually. As part of the recertification process, the Inspector General reviews a Unit's application for recertification and may conduct on-site visits. Additionally, the MFCUs are required to submit annual reports to the Inspector General. These reports include specific statistical data required by federal legislation on the number and type of cases under investigation, the number of convictions obtained and the number of dollar recoveries to the Medicaid program. The day-to-day supervision of a Unit rests with the parent agency.


8. How do Medicaid fraud cases typically arise?

While specifics may vary from state to state, a primary source of referrals is the agency responsible for auditing and reviewing Medicaid provider claims, the Medicaid agency. Other significant sources of referrals are the MFCUs in other states as well as other law enforcement agencies.

In Michigan, there are multiple "co-locations" to make primary referrals, but nobody does it. The investigative reports fade into the shadows of internet archives, and rather quickly, I must say!

This is one of my favorite examples of the non-existence of referrals in Michigan:

Michigan Office of the Auditor General, Audit Report, Financial Audit Including the Provisions of the Single Audit Act of the Department of Human Services, October 1, 2004 through September 30, 2006, Report #: 431-0100-07, (Pages 101-102). Thomas H. McTavish, C.P.A., Auditor General. (Released August 2007).

“DHS is primarily responsible for the expenditure of Foster Care: Title IV-E Program funds.

DHS has a contract with Wayne County to provide funding to Wayne County for eligible juvenile justice children. DHS considers Wayne County to be a subrecipient.

In order to be reimbursed, Wayne County submits a billing, which lists the Wayne County juvenile justice children for whom they are requesting reimbursement. DHS does not verify the eligibility of the children for whom they are paying. We were informed by DHS that the documentation would be retained by Wayne County because it was Wayne County that was responsible for continued eligibility determination. However, in our discussions with Wayne County, we were informed that it was DHS who was responsible for the continued eligibility determinations. The contract between Wayne County and DHS was silent on who was responsible for the continued determination.

As the grantor of the federal funds, OMB Circular A-133 requires DHS to monitor the program to ensure that the funds are expended for only eligible children. Because of the lack of understanding between the two parties and the lack of documentation for the items we reviewed, we have questioned all of the amounts provided to Wayne County for the two years ended September 30, 2006.” (Emphasis added)

The Audit Report continues to say in part:

“If DHS did not improve, it faced a possible penalty of $22 million”…. “The U.S. Department of Health and Human Services conducted the second eligibility review of DHS’s case files for foster care maintenance payments issued between April 1, 2006 and September 30, 2006. Prior to the review, DHS conducted an extensive case file review to identify cases that did not meet Foster Care: Title IV-E Program eligibility requirements. For cases that DHS determined did not meet the Foster Care: Title IV-E Program eligibility requirements, DHS changed the funding source on the cases to a funding source other than Foster Care: Title IV-E Program before April 1, 2006… As a result, those cases were not in the population reviewed during the federal review…The federal review concluded that DHS was in substantial compliance with federal eligibility requirements for the period April 1, 2006 through September 30, 2006.

We issued a qualified opinion on the Foster Care: Title IV-E Program. Our conclusion is different from the federal review because our sample included cases from the entire audit period.

RECOMMENDAITONS
FOR THE THIRD CONSECUTIVE AUDIT, WE RECOMMEND THAT DHS IMPROVE ITS INTERNAL CONTROL OVER THE FOSTER CARE: TITLE IV-E PROGRAM TO ENSURE ITS COMPLIANCE WITH FEDERAL LAWS AND REGULATIONS REGARDING ACTIVITIES ALLOWED OR UNALLOWED, ALLOWABLE COSTS/COST PRINCIPLES, AND ELIGIBILITY.

We also recommend that DHS improve its internal control to ensure compliance with federal laws and regulations regarding subrecipient monitoring.”

TRANSLATION: "TAG, YOU'RE IT!"


9. How do the multi-state/federal global settlements arise and how are they handled?

Medicaid fraud global settlements generally arise in connection with a U.S. Department of Justice investigation against a Medicare provider. When resolving these Medicare cases, the federal government, often at the request of defense counsel, turns to the state MFCUs because it cannot settle the Medicaid portion of the case without the Units. Moreover, defense attorneys are unlikely to settle the case without the affected states because each state has the authority to exclude a convicted provider from its health care programs. The Department of Justice typically contacts the National Association of Medicaid Fraud Control Units about a potential settlement, and the President of the Association appoints a settlement team which usually consists of three to four members.

Michigan has no exclusionary database because Medicaid Fraud in child welfare programming is never referred for prosecution. In the Michigan Auditor General Annual Report 2008, the imperative was revisited for a fourth time, for Department of Human Services to engage in contractual debarment and assessing sanctions for questionable and improper payments, and lack of internal controls.

10. What federal consequences follow a felony conviction for Medicaid fraud?

Under federal regulations, providers who are convicted of a program related offense are excluded for a minimum of five years from receiving funds from any federally funded health care program, either as a health care provider or employee. Often, this sanction has a greater impact on the convicted individual and the provider community at large than the criminal penalties assessed in the case.

The world eagerly awaits the first felony conviction in Michigan.

11. What is the National Association of Medicaid Fraud Control Units (NAMFCU)?

The National Association of Medicaid Fraud Control Units (NAMFCU) was founded in 1978 to provide a forum for a nationwide sharing of information concerning the problems of Medicaid fraud, to improve the quality of Medicaid prosecutions by conducting training programs, to provide technical assistance to Association members and to provide the public with information about the MFCU program. All 50 MFCUs are members of the Association. NAMFCU is headquartered in Washington, D.C. and is staffed by a Counsel, an Association Administrator and a part-time Association Assistant.

Here is my take on the National Association of Medicaid Fraud Control Units:

SQUAMULOUS LAGS.

I submit that NAMFCU needs to be put on the H.E.A.T. "laundry list."

New York AG Announces Medicaid Fraud Unit Criminal Convictions

ATTORNEY GENERAL CUOMO ANNOUNCES MEDICAID FRAUD UNIT SETS RECORD WITH 148 CRIMINAL CONVICTIONS IN 2009
Cuomo’s Medicaid Fraud Control Unit Also Recovers Over $283 Million in 2009
~
Cuomo Recovers Over $660 Million in Taxpayer Funds in First Three Years as Attorney General

NEW YORK, NY (April 12, 2010) - Attorney General Andrew M. Cuomo today announced that his Medicaid Fraud Control Unit (MFCU) obtained a record 148 criminal convictions across New York and recovered over $283 million in 2009. The information is detailed in his office’s Annual Report submitted today to the Secretary of the U.S. Department of Health and Human Services. The entire report can be found at www.ag.ny.gov/media_center/2010/apr/mfcu_2009.pdf.

In Cuomo’s first three years as Attorney General, MFCU has recovered over $660 million in taxpayer funds. As the largest unit within Attorney General Cuomo’s division of criminal justice, MFCU investigates and prosecutes Medicaid fraud as well as patient abuse and neglect, and served as the federal model for the creation of the national Medicaid fraud control unit program.

“Our Medicaid Fraud Control Unit continued to be a national leader in 2009, garnering a record number of criminal convictions and recovering hundreds of millions of taxpayer dollars,” said Attorney General Cuomo. “MFCU’s mission is clear - protect vulnerable patients from neglect and abuse while ensuring taxpayer dollars are safe and secure. I am confident that in 2010 MFCU will continue building on this nationally recognized record of excellence.”

The 2009 Annual Report details MFCU’s major criminal and civil cases for the past year and the $283 million in recoveries. MFCU also obtained a record 148 convictions. In addition, MFCU was honored with two awards last year from the Health and Human Services Office of the Inspector General (OIG). For the first time, MFCU was named Medicaid Fraud Control Unit of the Year for its work in 2008. In addition, the Inspector General also awarded members of MFCU with the 2009 Cooperative Achievement Award in recognition of their outstanding work on the civil settlement with Eli Lilly, which resolved allegations that the company illegally promoted Zyprexa for off-label uses. New York recovered $91 million in that settlement.

The report highlights MFCU’s activities and major cases during 2009 and includes data regarding the 148 convictions and $283 million in recoveries. Some of the cases, settlements, convictions, and achievements described in the report include:

* Operation Home Alone: The Attorney General’s Operation Home Alone investigation of corruption in the home care industry during 2009 resulted in civil settlements with licensed home health care services and certified home health care agencies totaling $51.7 million and 25 criminal convictions. As part of this ongoing investigation, MFCU indicted two home health aide training schools and their owners for selling phony home health aide certificates - resulting in millions of dollars of unlawful Medicaid billings. In addition, a home care agency and its owner were convicted of stealing more than $1 million for nursing services provided by unlicensed nurses in the State of New York. To date, 125 defendants have been charged and approximately 100 have been convicted through Operation Home Alone.
* Pharmaceutical Settlements: MFCU participated in settlements with several pharmaceutical companies, including Eli Lilly, Pfizer, Mylan Pharmaceuticals, Astra Zeneca, and Aventis for off-label marketing, kickbacks, misreporting prices, and other fraud.
* Drug Diversion and Prescription Fraud: In 2009, MFCU secured a 3 year prison sentence for a doctor who was convicted of selling prescriptions, which were then filled, and sold on the street - all paid for with Medicaid money. In addition, a pharmacist was sentenced to one year in jail for billing Medicaid over $1 million dollars for prescription drugs that were never dispensed.
* Program Fraud: An upstate hospital debt collecting company and its owner were indicted for scamming Medicaid for over $700,000 by bribing a local Department of Social Services employee to assist in approving Medicaid coverage for certain hospital patients. The DSS employee pleaded guilty and is cooperating in the ongoing prosecution. MFCU filed a civil suit against the debt collecting company seeking over $2 million dollars in civil damages and penalties under the False Claims Act and Social Services Law.
* Nursing Homes: MFCU filed criminal charges and a civil lawsuit seeking damages of $5 million against a nursing home and its owner for paying kickbacks to a hospital employee for patient referrals ultimately billed to Medicaid. By law, patients are entitled to a choice of 5 nursing homes, but the hospital employee referred the patients to nursing homes he knew would refuse the referral, leaving the patients no choice but to go to the corrupt home. As a result of this scheme, patients were denied a real choice of where they or their loved ones would be admitted.
* Dentists: A judge issued a $15.6 million judgment against two dentists who operated a mobile dentist business and who knowingly employed an individual with a prior felony conviction. The convicted felon had also been barred from participating in the Medicaid program and paid kickbacks for Medicaid patient referrals. The felon made illegal payments to have “runners” and “hustlers” refer Medicaid patients to the buses for treatments billed to Medicaid.
* Hidden Camera Investigations: Cuomo’s MFCU leads the nation in using hidden surveillance to investigate neglect and abuse in nursing homes. MFCU arrested 22 current and former health care workers at nursing homes in Troy and Buffalo just last month. To date, 30 nursing home employees have been convicted based on undercover video.

Under the federal legislation that created the Medicaid fraud control unit program in 1978, the federal government funds 75 percent of Medicaid fraud control units’ budgets and states fund 25 percent. The U.S. Department of Health and Human Services administers the federal grant funds for the nation’s 50 Medicaid fraud control units. The New York MFCU’s own monetary recoveries fund New York State’s share of the unit’s budget with the remainder of the money returned to the New York State Department of Health’s Medicaid budget.

Michigan Medicaid Fraud Control Game

There are times when I become just utterly disgusted with blatant lies.  This is one of them.

I recently submitted a FOIA to find information on Michigan's Medicaid Fraud Control Unit.  I called the Office of Attorney General who referred me to the Michigan Department of Community Health.

The FOIA was quite simple.  All I did was to take the federal statute, and cut and paste the criteria for the Medicaid Fraud Control Unit.

  1. Details of Statewide authority to prosecute individuals for violations

  of criminal laws with respect to fraud in the provision or administration
  of medical assistance under the State plan;

  2. Assurances for referral from all State Departments for violations of

  criminal laws with respect to fraud in the provision or administration of
  medical assistance under the State plan;

  3. The organizational structure and chart;
  4. The number of employees, description of duties and qualifications for
  all professional positions;
  5. Federal Memorandum of Agreement and/or orders, if any;
  6. Copy of agreement with the Department of Community Health;
  7. Annual reports of Fiscal Years 2001, 2002, 2003, 2004, 2005, 2006,

  2007, 2008, and 2009; and,

  8. Projected operations and budget for FY 2010

The reason why is because I was tired of the games and it personally hurts.

Medicaid fraud in child welfare is horrific and no one will speak upon this crime.  For years, there are reports generated by the State Auditor General and it gets brushed aside by legislators.  The most recent report documents almost $5 billion in questionable costs.  The only thing that happened was a hearing in Lansing where everyone looked around the room staring at each other, rambling big words on correcting the situation.  It was a joke.

I filed an action to make the state, in accordance to its own laws, stop Medicaid fraud by referring to the Attorney General for prosecution and recovery.  Within a few weeks of my filing, the following was produced:

Michigan Medicaid Integrity Program

After some public posturing, the position of Medicaid Inspector General was created....
Michigan Executive Order On Creation of Health Services Inspector General
...in the Department of Community Health.

This takes us back to the FOIA.

I received, today response to my query on the structure, operations and authority of the Medicaid Fraud Control Unit.  It was a package with an organizational chart of the Department of Community Health, a copy of Senate Bill No.1152 and a bill.

The Department has identified approximately 19,460 pages of documents responsive to your request.  Using the hourly wage of the lowest paid department staff capable of searching for, retrieving, reviewing, examining, and separating exempt material, the cost for processing the request is calculated as follows:

•   20 hours labor @$22.15 per hour to search and retrieve records..............................................................................................................$443.00
•   20 hours labor @$22.15 per hour to review, examine and separate exempt from non-exempt records..............................................................................................................$443.00
•    19,460 pages @ .25 per page.......................................................................$4,865.00
• Total..............................................................................................................$5,751.00

TRANSLATION:  We do not have the information you requested because it does not exist.  If we charge you exorbitant amounts, knowing that you could never possibly pay it and pretty secure in the fact that you will you use the information in litigation against us, we ain't giving you shit.

I can easily FOIA the U.S. Department of Health and Human Services Office of Inspector General and say,

"Dr. Levinson, did you know the stuff Michigan Office of Attorney General sends in to garner your approval for its Medicaid Fraud Control Unit does not exist?  The Department of Community Health, State Medicaid Director, just sent me a FOIA response saying it does not exist so I was wondering if you would have your staff send it to me, because, of course, you did approve its operations and fund 90% of the Medicaid Fraud Control Unit which does absolutely nothing to end Medicaid fraud as the state does not comply with its own assurances for referral when there is suspect of Medicaid fraud.  I would really appreciate it if you would send those docs to me so I can give them to the Office of Attorney General and the Department of Community Health.  I promise to upload each doc to my Scribd account.

I will do that later.  Stay tuned.

I am a public official.  That means whatever I say goes on public record; therefore, let the record reflect that I am officially calling upon the Democratic candidate for the Office of Attorney General for the State of Michigan, David Leyton, to address the issues of the Medicaid Fraud Control Unit and what will be done to end Medicaid fraud in child welfare.

My following may be small but those who visit my site are powerful.  Let Mr. Leyton know I will be looking for him at Cobo Hall.

Iowa cracks down on Medicaid fraud 

Kathryn Milton was a 96-year-old resident of Des Moines' Calvin Community nursing home when two of her caretakers began stealing checks from her room.


Over a period of four weeks, nurse aides Jolene McNew and Jodi Smith repeatedly forged checks from Milton and two other residents of the nursing home, stealing $9,415.


At the same time that was happening, a convicted burglar named Vincent Stroman was running We Care Wheelchairs, a Sioux City company paid by Medicaid to provide transportation for the disabled.

Over a period of several months, Stroman submitted a series of bogus bills for fictitious trips, collecting an extra $153,338 from the taxpayer-funded program.


The cases appear to have little in common, but each was investigated by the Iowa Department of Inspections and Appeals' Medicaid Fraud Control Unit, an 11-person task force that last year quietly pursued dozens of cases involving elder abuse and Medicaid fraud.


Over the past two years, the unit has stepped up its enforcement efforts, ferreting out more forms of fraud and winning significantly more criminal convictions.

It's a unit of government that pays for itself - and then some. During the 12-month period that ended in March, the unit recovered $11.1 million in Medicaid overpayments. The unit's expenses consumed only $1.1 million in state and federal resources.


Dean Lerner, the head of the inspections department, says the unit's work - fighting elder abuse and recovering taxpayer money lost to health care fraud - is critical.


Iowa has one of the nation's oldest populations, he said, and every dollar lost to Medicaid fraud is a dollar that can't be used to care for the poor and the sick.

Since late 2008, the unit has been headed by John Judisch, a former Polk County prosecutor who has aggressively pursued cases of fraud and abuse. Since Judisch took over, annual Medicaid overcharges recovered by the unit have grown from $1.7 million to $11.1 million.


Criminal convictions have increased from 24 per year to 62 per year.


For example, nurse aides McNew and Smith were convicted of felonies and placed on probation. Stroman, who tried to improperly collect thousands of dollars from Medicaid, was recently sentenced to 15 years in prison.

"The data doesn't lie," Lerner said. "The data shows we have been very successful."


While 49 of the 50 states have their own Medicaid fraud control unit, the Iowa office appears to be among the most cost-effective operations.


Among the states, only 12 have fewer employees in their fraud units, yet Iowa ranks seventh in terms of criminal convictions.


Judisch attributes much of the success to his staff's ability to juggle a wide range of cases. The better they get at their jobs, he said, the bigger their caseloads.

"Criminals get very good at coming up with new ways to commit fraud," he said. "They'll expend $1,000 worth of effort in coming up with ways to steal $100."






Last month, Gerald Bruening pleaded guilty of stealing $34,769 from the Marian Home care facility in Fort Dodge, where he had worked as the administrator.


Between September 2005 and August 2008, Bruening took money from the facility, used it for personal expenses and then factored those purchases into the facility's federal cost reports to justify increased Medicaid funding from the state and federal government. Bruening was sentenced to two years of probation.

In Clinton last week, Fire Chief Mark Regenwether and the city's emergency medical services director, Andrew McGovern, were fired after the city agreed to pay $4.5 million to settle a lawsuit alleging Medicaid overcharges related to ambulance calls.


The lawsuit was brought by one of the city's own firefighters, who claimed the city had falsely categorizing routine ambulance calls as trips that required advanced life support measures.


The scheme enabled the city to collect a higher rate of payment from Medicaid and Medicare.

Some fraud cases involve national settlements with major drug companies or other health care providers doing business in multiple states. In those cases, Iowa shares in the millions of dollars recovered by investigators working at the national level.






The Iowa fraud unit has been particularly successful in what Judisch calls the homegrown Medicaid-fraud cases: Iowa-focused investigations handled largely by his own staff.


In 2008, those cases accounted for just $7,543 in money recovered for taxpayers through fines and restitution. In the past three months, however, the unit's homegrown cases alone have accounted for $231,238 in recoveries.

The increased focus on Medicaid fraud involves a trade-off.


The unit once focused more of its efforts on elder abuse - cases that now get less attention from the unit. Last year, the unit investigated 139 complaints of abuse, a significant drop from the previous year's 233 investigations.


Judisch and Lerner say the shift in focus makes sense given the fact that information on suspected abuse is always shared with county prosecutors, local law enforcement officials and state care-facility inspectors.

"So while Medicaid Fraud Control Unit may not deal with some of these cases, they are being addressed by others," Lerner said.


Federal officials say state and federal agencies lose at least $60 billion each year to various forms of health care fraud. Those losses coincide with recent cuts in government services and increased demand for public assistance.


"It makes good financial sense for Iowa to continue to enhance these recovery efforts," Lerner said.

"We have a limited number of dollars to meet people's needs and we don't want any of them to go to waste," Lerner said.

Alaska Medicaid Fraud Control Unit Neglects Youth

What about the youth? Is there a reason the States Medicaid Fraud Control Units do not provide the same protection for children? Why is there Medicaid Fraud in Child Welfare?

It's called Child Protective Services (CPS).

The law enforcement functions overseeing children were bifurcated and housed within a newly created agency within the executive branch, leaving the public impression that it was transparent. Freedom of Information Act laws allow anything dealing with children to be sealed and sequestered from public scrutiny. The only information released to the functions of child welfare are done through propaganda campaigns and fallible curriculum.

Power to enforce the law was bestowed upon an agency that does no take ant oath of office to execute the duties of child welfare with respect to constitutional rights and the laws of the land.

Simply put, any Medicaid fraud performed in child welfare will never be prosecuted and recovered.

Medicaid Fraud Unit Expands into Abuse and Neglect Cases

June 21, 2010
Monday

Anchorage, Alaska - The Alaska Medicaid Fraud Control Unit in the Department of Law announced today they recently obtained criminal convictions of two women in a case from late 2007 in which an 81-year-old veteran was abused.

The unit, formed in 1992 to focus on fraud, recently has expanded its scope into abuse and neglect cases.

Alejandra A. Schaub, 65, formerly of Anchorage, pleaded guilty to a felony charge of domestic violence assault on June 7. Ofelia Guiel, 47, pleaded guilty to reckless endangerment on June 8. At the time of the crime, Schaub was providing care for the elderly veteran in Guiel's Anchorage home.

The abuse came to light after Schaub took the victim to appointments at the Veterans Administration clinic and at Elmendorf Air Force Base. Various caregivers voiced suspicions of abuse to Guiel, who disregarded them and returned the victim to the home, where Schaub continued the abuse.

The Alaska Medicaid Fraud Control Unit was notified of the abuse in 2009. The victim previously had not revealed the identity of the abuser because he relied on her for assistance with his daily life. After he was transferred to another assisted living home, he disclosed that Schaub had broken his finger, flattened his nose and deformed his ears. Schaub fled the state, but with the assistance of the U.S. Marshall's service, she was found in Nevada and returned to Alaska.

Schaub, who had no prior record, was sentenced to a year in jail, with six months suspended, and was given probation for three years, with conditions that she have no contact with the victim and provide no care for elderly or infirm individuals. Guiel received a 90-day suspended jail sentence and also was placed on probation for three years. She is also prohibited from having any contact with the victim and from working in the Alaska Medicaid program for five years.

"Alaska will continue to ferret out those who prey on our most vulnerable, and will prosecute them to the fullest extent of the law," said Deputy Attorney General Rick Svobodny, head of the criminal division in the Department of Law.

The Alaska Medicaid Fraud Control Unit is funded primarily by the federal government to investigate fraud and patient abuse and neglect, and is staffed by investigators, and auditor and a prosecutor. The unit has participated in nationwide actions against pharmaceutical companies that have resulted in the return of millions of dollars that had been siphoned from the state Medicaid program.

Last year, the unit concluded a case against one of the most significant known defrauders of Medicaid services in Alaska history. Sherry T. Trotter, president of On Call Nursing of Alaska, pleaded guilty to a felony theft charge and was sentenced to 36 months in prison, 28 months suspended, and ordered to pay more than $800,000 in restitution.

U.S. DHHS OIG 2017 Medicaid Fraud Control Unit Report Is Out

It is that time of the year when the U.S. Department of Health and Human Services Office of Inspector General comes out with its annual report, with data that is 2 years late, on the wonderful things that have been done in the States Medicaid Fraud Control Units.

And just like every year, there is absolutely nothing, nada, nixt, rein, done with Medicaid Fraud in Child Welfare.

Why?

The Medicaid Fraud Control Unit is located, typically, with the States Attorney General because you need a law enforcement power to prosecute and recover the false claims.

Then, the States have things called False Claims Acts that are drawn up to be so restrictive, no one can bring forth a claim.

Let us not forget to mention the National Association of Medicaid Fraud Control Units that refuse, under any circumstance, be it an act of God or an act of war, to speak upon Medicaid Fraud in Child Welfare.

The original MFCU law was set up for the aged.

Child Welfare was set up for the young.

This is where the contemporaneously inherit conflict of interest exists.

"How can States Attorney General advise and advocate at the same time?"

Besides, there is too much money involved and no one cares. 

Here is the report on Michigan:

The Unit made workspace available to an OIG agent within the Unit offices. Co-location facilitated communication between the MFCU and OIG in assessing potential fraud referrals and working joint cases. Case management tools Unit management and the Michigan Department of Licensing and Regulatory Affairs (LARA) developed a streamlined process for referring cases of patient abuse or neglect. This process helped to ensure that referrals from LARA were consistent with the Unit’s statutory functions, thereby promoting Unit efficiency and case flow. 

Michigan Co-location of Unit and OIG staff:  The Unit made workspace available to an OIG agent within the Unit offices. Co-location facilitated communication between the MFCU and OIG in assessing potential fraud referrals and working joint cases. Case management tools Unit management and the Michigan Department of Licensing and Regulatory Affairs (LARA) developed a streamlined process for referring cases of patient abuse or neglect. This process helped to ensure that referrals from LARA were consistent with the Unit’s statutory functions, thereby promoting Unit efficiency and case flow.

There is no referral mechanism within Michigan administration, particularly LARA, as it has dismantled its oversight function of child welfare private contracts, switching over to the "self report" model, to report Medicaid Fraud in Child Welfare and "The Elected Ones" will never speak upon it.

Gotta fund those campaigns!

This is the only mention of children:

Inpatient Psychiatric Services for Individuals Under Age 21 criminal 17 civil 6 total 23

Medicaid Fraud Control Units Fiscal Year 2017 Annual Report by Beverly Tran on Scribd

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Beverly Tran on Proposed Revision of Performance Standards for State Medicaid Fraud Control Units, December 5, 2011

Never before has anyone ever spoken of Medicaid Fraud in Child Welfare with such finesse and no one else ever will because I have all intentions of running this game.

What is a Medicaid Fraud Control Unit?  According to the National Association of Medicaid Fraud Control Units, it states:

Medicaid provider fraud costs American taxpayers hundreds of millions of dollars annually and hinders the very integrity of the Medicaid program. State Medicaid Fraud Control Units (MFCUs) have long been in the forefront of health care fraud enforcement. A Medicaid Fraud Control Unit is a single identifiable entity of state government, annually certified by the Secretary of the U.S.Department of Health and Human Services, that conducts a statewide program for the investigation and prosecution of health care providers that defraud the Medicaid program. In addition, a MFCU reviews complaints of abuse or neglect of nursing home residents. A Unit may review complaints of the misappropriation of patients’ private funds in these facilities. The Unit is also charged with investigating fraud in the administration of the program and for providing for the collection or referral for collection to the single state agency and overpayments it identifies in carrying on its activities. 

The Ticket to Work and Work Incentives Improvement Act of 1999 extended the jurisdiction of the Units to allow them, with the approval of the Inspector General of the relevant federal agency, to investigate fraud in any federally funded health care program, such as Medicare. This authority is limited to those cases that are primarily related to Medicaid. This law allows the MFCUs the option to investigate complaints of abuse or neglect of those residing in board and care facilities, regardless of the source of payment.

As one can easily see, the population of child Medicaid is omitted.  This is why groups such as Children's Rights has to file lawsuits to get States to protect the children in the foster care system.

Furthermore, this is the reason why there are no statistical reports of murder, rape, torture and drugging children in foster care.  Child Welfare Services in foster care are funded through Targeted Case Management,  a.k.a. Medicaid; therefore, MFCU is suppose to investigate abuse and neglect in foster care but does not.  The typical state reaction to reports of abuse and torture in foster care is to move the child to a new placement.  Some states have special "death squads" to secretly investigate and destroy evidence of a child murder in foster care.  These reports are never made public, it is rare that anyone is prosecuted, and not one penny of Medicaid is recovered.

By not investigating abuse and neglect in foster care, a direct correlation is constructed to another neglect3ed area of regulation in Child Welfare, the contracts and services.  Here the amounts of Medicaid fraud will nationally rise into the billions.

These MFCU were created the same time of CAPTA.

Without further adieu, experience the publishing of why Medicaid Fraud in Child Welfare is the nation's dirty little secret.

Public Comment of Beverly Tran on Proposed Revision of Performance Standards for State Medicaid Fraud Contr...

Federal Register Notice: Proposed Revision of Performance Standards for State Medicaid Fraud Control Units

Stop Child Medicaid Fraud

Michigan and Feds Keep Ignoring Billions in Medicaid Fraud

The Department of Health and Human Services has completed an onsite review of the Michigan

Medicaid Fraud Control Unit.  As a standard review, it went relatively well except for the fact that the inspections always omit any reference to identifying Medicaid fraud in child welfare.

The following is a sample what the Inspectors look for in conducting an onsite review.  My comments show how child welfare is not included in the scope.

4. A Unit should take steps to ensure that it maintains an adequate workload through referrals from the single State agency and other sources. In meeting this standard, the following performance indicators will be considered: 

a. Does the Unit work with the single State Medicaid agency to ensure adequate fraud referrals? 

The Unit works with state business licensing agency but the state does not enforce referral policy for child welfare fraud.  The Office of Children's Ombudsman has never, ever referred a case of Medicaid fraud to the Unit.

b. Does the Unit work with other agencies to encourage fraud referrals? 

Nope.  If a child welfare provider is found to have filed false Medicaid claims, the worst that will happen will be that the organization will restructure under a different name.  The Bureau of Children and Adult Licensing does not refer out cases of suspected Medicaid fraud in child welfare as it will pose a compromise to privacy laws of child welfare.  The Unit needs to train and establish policy on referring suspected cases of Medicaid fraud in child welfare.

c. Does the Unit generate any of its own fraud cases? 

There has never been a prosecution or recovery of Medicaid fraud in child welfare.

d. Does the Unit ensure that adequate referrals of patient abuse complaints are received from all sources? 

Of course not.  Patient abuse and neglect come from the Long-term care Ombudsman which strictly deals with adults.  The Children's Ombudsman keeps its investigations sealed, does not investigate a majority of the claims filed and in certain instances, will consider the claim to be "Valid-Not-Opened".

I personally know of a Detroit child placing agency which currently engages in Medicaid fraud.  The clients are living on the streets yet the agency is billing for phantom Medicaid funded services.  Michigan Children's Institute has the most occurrences of Medicaid fraud as it has never, in the history of its existence, been audited.

David Tanay is a great Director of the Unit.  I hope Michigan's politics do not hog tie him in developing new policy to stop Medicaid fraud in child welfare.

HHS Michigan Medicaid Fraud Control Unit Report 2013 by Beverly Tran

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HHS Medicaid Fraud Control Units 2016 Annual Report & Me

When dealing with Medicaid Fraud in Child Welfare, the Medicaid Fraud Control Units are useless,

pursuant to statutory authority.

Yes, that is correct, Mediciad Fraud in Child Welfare is the biggest racket where one is, guaranteed, never to be criminally prosecuted, nor civilly penalized, because, it is all in the best interests of the child.

Let us examine the Michigan.

Rumor has it Michigan is so jacked up when going after Medicaid Fraud, that the U.S. DOJ and OIG HHS have teamed up to use the state as an example of "what not to do" when going after Medicaid Fraud.

A few years ago  I had FOIA'd for its mandated annual report to the OIG.  They told me they did not have one.

Seriously.

Then, this one time I had to call the U.S. OIG HHS to let them know that they had substantial errors in its review of Michigan's False Claims Act.  At least they thanked me.

So, for your reading pleasure in learning about MFCUs, allow me to do what I do best, in fuchsia.

Transcript for audio podcast: Medicaid Fraud Control Units

[Don White] What role does OIG play with State Medicaid Fraud Control Units and why are they important? I'm Don White in public affairs with the Office of Inspector General, and today, we're here with Richard Stern, OIG's director of program oversight for the Medicaid Fraud Units, and from our regional Office of Investigations, Special Agent in Charge Shimon Richmond of the Miami region. Shimon, what is a MFCU?

Greetings Don, Richard and Shimon.  I am here to bring jolly into your professional lives and do something about Medicaid Fraud in Child Welfare.

[Shimon Richmond] Well, Don, aside from being an awkward acronym, MFCUs are Medicaid Fraud Control Units. And as that name suggests, they investigate and prosecute Medicaid provider fraud, as well as patient abuse and neglect in health care facilities. They are state-based agencies and there is one of each in 49 states and the District of Columbia.

Well, Gentlemen, you failed to state that the States MFCU were never designed to go after Medicaid Fraud in Child Welfare, and have yet, to the date of this post, publicly addressed the fact that child welfare programs of the Adoption Safe Families Act were enshrined by the Congress to be impervious to any form of external scrutiny of its operations through IRS non-profit certifications.

[Don White] Well Richard, so you understand this best, why do we need Medicaid Fraud Control Units anyway?

[Richard Stern] Well, while we hear a lot about Medicare Fraud, involving the program for the elderly and the disabled, total taxpayer costs are actually higher in Medicaid, than in Medicare, with total yearly expenditures for Medicaid of over $500 billion dollars. And fighting fraud in Medicaid can be especially challenging. Each state runs its own program, So the rules vary from state to state. And we don't have good data at the national level. As we often hear, once you've seen one Medicaid program, you've seen one Medicaid program.

Guys, you failed to mention that child welfare programming, now, almost completely privatized, is untouchable when it comes to its state operations.  See, child welfare so-called oversight has been placed in the make shift huts called ombudsman offices, due to the fact that the original statute for the creation of MFCUs was exclusively designed for the aged.

Ombudsman offices of the States are then, on a secondary level, with watered down oversight authority of referral to law enforcement, further constrained due to privacy laws.  This means that there are no mandates for the States to adopt any policies for mandatory referral of suspected Medicaid Fraud in Child Welfare, to the State Attorneys General for prosecution, recovery, sanctions, exclusions, contractual debarment or criminal prosecution.

Why, you may ask?  Well, boys, the reason is two-fold.  First, you cannot audit God, meaning, any IRS charity/non-profit cannot be audited.  Secondly, anything dealing with child welfare is exempted and excluded from FOIA, as well as any other public disclosure, in the best interests of the child, you know.

[Don White] I understand that MFCUs have an important role in investigating and prosecuting patient abuse and neglect in nursing homes and other health care facilities as well, is that true?

[Richard Stern] Yes, that is true.

Richard, I understand that MFCUs do not do a damn thing about children being legally kidnapped by Child Protective Services, being drugged, raped, beaten and tortured in foster care, where each and everyone of these activities are cost-reimbursed through Medicaid.

[Don White] I can see that investigating Medicaid fraud would certainly be challenging given how different each State's programs can be. So since fighting Medicaid fraud is an OIG priority and a Top Management Challenge for the U.S. Department of Health and Human Services, I'm wondering how OIG works with these State MFCUs? Richard?

The OIG does absolutely nothing to work with the States MFCUs because the administrators of the HHS Children and Families Administration are the same people who were running these fraudulent child welfare programs, grant research and are, also, lobbyists.

I would be so remiss not to mention that the legislators benefit from the campaign contributions from the booty of Medicaid Fraud in Child Welfare to keep the same lack luster culture in place of willful ignorance to the blatant defalcation through double billing and phantom billing.

[Richard Stern] Well, yeah. Well, OIG administers a grant to each of the units that provides 75% of their funding. We also set performance standards, we review each state's program, we provide technical assistance identify best practices, and we collect and analyze statistics that we make available to the public on OIG website.

And you still fail to acknowledge that Medicaid Fraud in Child Welfare is an intentionally omitted variable in the annual report, I have so graciously provided, below.

Here are the data for FY 2016 Medicaid Fraud in Child Welfare prosecuted and recovered through the States MFCUs: 99 - missing data; $0.00

[Don White] How does that grant program work, Richard?

[Richard Stern] Well, as part of the Medicaid program, each of the States is required to have a MFCU or to receive a waiver. And the way it works, in exchange for receiving Federal matching funds, the States run a self-contained unit that includes investigators, auditors, and prosecutors or other attorneys. This model of having prosecutors work side by side with investigators and auditors has proven to be very successful. Most of the units are in the State Attorney General's Office and either prosecute cases themselves or refers cases to other State, County, or Federal prosecutors. MFCUs also collaborate closely with their State Medicaid programs, the OIG Office of Investigations and the FBI, as well as Department of Justice and U.S. Attorney offices nationwide.

Hold on a minute.  Let me put my 2 cents in about those waivers.  Those waivers created another quagmire when it comes to conflicts of interests, but let us start with the States Attorney General.  

How is it the States Attorney General can prosecute contractual entities it contemporaneously advocates, while prosecuting cases in child welfare proceedings?  See, it is like this.  The state contracts privately with a child placing agency to provide Targeted Case Management services to a foster child.  The agency proceeds to submit fraudulent Medicaid billing for cost reimbursement and uses those exact same need for services as legal standing to proceed with termination of parental rights, which is litigated by the States Attorney General.  

So, what some states did was to accept the waiver and house its MFCUs in places other than the AG, even though there are only a few states which have done this.  Placement of its MFCUs are then ensconced deep within the same agency which reimburses Medicaid costs.  Yes, this is an inherent conflict of interest but, under ASFA, there is a "right to lie" when submitting the false claims of Medicaid cost reimbursements in child welfare.

To top all this off was another set of Medicaid waivers in child welfare.  These waivers allowed States to use Targeted Case Management funding for what they attempted to coin as "home-based/community-based" services under family preservation.

[Don White] But I'm wondering how successful have these MFCUs been when working with OIG in fighting Medicaid fraud?

I am going to go out on a limb and say that these MFCUs have not been very successful when working with OIG in fighting Medicaid fraud because Medicaid fraud is a major funding mechanism when it comes to human trafficking.  Oh, you do know human trafficking is exactly what child welfare is, right?  Right?  I'll let Shimon answer that.

[Richard Stern] I'll let Shimon answer that. Florida, and especially South Florida, is one of our hot-spots for health care fraud.

[Shimon Richmond] Sure thing. So around the country, the OIG works a lot of cases with the Medicaid Fraud Control Units. In 2016, our Medicaid cases resulted in 312 indictments, 348 criminal actions, and 222 civil actions. These Medicaid cases - some of which also involved Medicare - resulted in almost $3 billion dollars in expected recoveries.

Shimon, you did not answer how successful the OIG has been in working with MCFUs in stopping Medicaid Fraud in Child Welfare and its human trafficking.  Around the country, Child Protective Services targets populations for Medicaid fraud billing opportunities through Targeted Case Management.

[Don White] So how important would you say these Medicaid Fraud Units are to your operations, Shimon?

[Shimon Richmond] Well Don, they're absolutely critical to our efforts.

So, what exactly are your efforts to stop Medicaid Fraud in Child Welfare?

[Don White] Can you give us some recent examples where your people worked with the MFCUs?

Hello?  Can someone please answer my question as to what are your efforts to stop Medicaid Fraud in Child Welfare?

[Shimon Richmond] Sure Don, we work with the Florida MFCU quite a bit. And there are several cases that come immediately to mind. First, working with the Florida MFCU, we charged 10 owners of a Miami-Dade county Assisted Living Facility with health care fraud and receiving illegal cash kickbacks in return for referring residents to a specific pharmacy. The pharmacy owner was sentenced not long ago, to federal prison and ordered to pay back more than a million dollars to the Florida Medicaid program. This ring was exposed by joint efforts between OIG agents and MFCU agents working in undercover capacity.

Have you guys ever hear of the Medicaid defalcation stories in residential institutions through what I like to call kiddie kickbacks?

[Richard Stern] You know I should also say, however, the MFCUs work many of their own cases without assistance from other agencies, and do so very successfully. MFCUs investigate, and prosecute, patient abuse or neglect in nursing homes, and hospitals, as well as in assisted living facilities. Sadly, the abuse of the elderly and other residents of these facilities has become a major social issue. These are difficult cases, and MFCUs are one of the few State or Federal agencies devoted to criminal prosecution of patient abuse or neglect.

Well, boys, if MFCUs can work on their own cases without assistance from other agencies, that would mean that the Unit would end up prosecuting its state attorney general by accessing information of child welfare cases without authorization, contaminating any evidence, leaving the state contractual entities to continue to fraudulently bill Medicaid.

[Don White] Well, Shimon, could these Medicaid Fraud Control Units be doing even more?

Let me answer that for you, Shimon.  Yes.  These Medicaid Fraud Control Units can be going after Medicaid Fraud in Child Welfare by starting with a public admission that it needs congressional help in implementing parallel jurisprudence and civil rights in child welfare.

[Shimon Richmond] Absolutely they could. But many of the MFCUs really need additional resources to fight the fraud in their jurisdiction. And currently there are no MFCUs in Puerto Rico or North Dakota. Also, the Medicaid Fraud Control Units need the legal authority to investigate and prosecute patient abuse or neglect in home- or community-based settings in addition to institutions. The current rules made some sense when Medicaid services were primarily provided in institution in times past, but as those services are increasingly provided in the home and the community, things really have changed.

Hey, I have a better idea and it will not cost as much.  How about setting up a bounty program?  I am not speaking upon the False Claims Act, as the victims of Medicaid Fraud in Child Welfare are, meeting the criteria of Title IV-A, are in the exclusive category of "The Poors".  No money, no justice.

So, instead of an impossible qui tam, how about an administrative program like the IRS Whistleblower program?  Yes, it will take time, but you will be doing "hands-free" data collection on Medicaid Fraud in Child Welfare, then, can run those data with program performance, well, let us just say the possibilities are endless.

[Richard Stern] Right. We will need Federal legislation to make that happen and there does seem to be interest for that happen on Capitol Hill.

I just told you guys that Medicaid Fraud in Child Welfare funds their political campaigns, so, of course, there is no interests on Capitol Hill, nor the White House.

[Don White] Well, I hope that this podcast has provided some helpful information on the important work by of the Medicaid Fraud Control Units.

And I hope that I have provided some helpful information on the important work the Medicaid Fraud Control Units do not do.

[Richard Stern] Thank you for the opportunity to speak about the work of the over 1900 MFCU professionals across the nation.

I would like to thank everyone who has taken the time to find out more on Medicaid Fraud in Child Welfare and the constraints of the States Medicaid Fraud Control Units.  Remember to sign up for your daily dose of me!

[Don White] Any last words, Shimon?

[Shimon Richmond] Well, just that the MFCU's play a critical role in protecting the taxpayers and the residents of health care institutions, so I'm happy to participate and glad that we can discuss this today.

[Don White] Thanks a lot.

Thank you, gentlemen, for allowing me the opportunity for another glorious castigation on the DOJ's and HHS' complete and utter failure to end Medicaid Fraud in Child Welfare.

On of these days, the world will finally listen to me.

Medicaid Fraud Control Units Statistical Chart 2016 by Beverly Tran on Scribd

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South Dakota Is Why HHS OIG Daniel Levinson Must Go Far Away

Well, well, well.  Look at what we have here.

The U.S. Department of Health and Human Services Office of Inspector General has issued a report on some of the "general compliance" issues within the State of South Dakota's Medicaid Fraud Control Unit.

Aww.

The HHS OIG said, "Bad South Dakota MFCU, bad."

They even went so far as to generate a podcast on the great things it is doing for the poor lil' Indians in South Dakota but here is my issue:

Daniel Levinson has got to go.

Yes, Levinson, the Inspector General of the DHHS has been at the helm for quite some time, and, for quite some time, Medicaid Fraud in Child Welfare has been utterly ignored, intentionally omitted from the political conversation for years.

HHS OIG Danny Levinson
contemplating the quagmire
of Medicaid Fraud in
Child Welfare

Levinson cannot say that he is unaware of Medicaid Fraud in Child Welfare because I have a big mouth and I have actually sat at the table in D.C. to have raised the issue, only to be met with silence, with mouths wide open, as the concept of incompetence within the administration went flying over their heads.

One reason why there is no public discussion of Medicaid Fraud in Child Welfare is because the States Attorneys General contemporaneously "advise and advocate" for its contractual fraudfeasors.

That is correct.  How can a State Attorney General prosecute what it defends?

Then there is the nasty issue of these MFCUs not being designed to even address child welfare fraud.

See, the original legislation, stemming from Walter Mondale's actions to protect the aging population from fraud within the Social Security programs excluded the children.

Child Abuse Prevention Treatment Act (CAPTA) came around and everyone thought it was the greatest invention since sliced bread as it established funding for economically struggling cities to create educational and employment opportunities for those historically excluded, for the purposes of "assimilating children of the poors".

No one would ever consider that there would be fraud in a child welfare program.  Nope, because most of this work was done in the name of God, non-profits, and everyone knows.... say it together with me...

"YOU CANNOT AUDIT GOD"

Then came the horrific Adoption Safe Families Act which set an expedited timeline to allowed fraudulent billing under Targeted Case Management, a Medicaid program, and also provided for, what I like to call the "shredding of the bills" through termination of parental rights.

As long as these States are without policies to refer child welfare fraud to the MFCU for prosecution and recovery, there will always be a few of those pesky "general compliance" issues found.

Do not even let me get started on advocating for the use of aggregate data to generate predictive models of abuse and neglect or the blatant refusal to even touch contract compliance and fraud within the Administration of Children and Families!

Just take a look, below, at the recently upheld decision on improper removals of Sioux children in South Dakota.  If this is not a working example of the lackadaisical stewardship of Daniel Levinson, I do not know what is.

Hey, Danny, time to retire!

You suck.

Feds fault state for Medicaid fraud efforts

A federal report on Wednesday criticized South Dakota’s commitment to fighting Medicaid fraud, finding the state is understaffed in a key area for rooting out fraud and abuse.

The report from the United States Health and Human Service’s Office of Inspector General was ostensibly a review of the state’s Medicaid Fraud Control Unit, or MFCU, within the attorney general’s office. Nationally, MFCUs are responsible for prosecuting Medicaid fraud cases, levying civil fines or prosecuting abuse and neglect cases.

Medicaid is a taxpayer funded health program for the poor.

The federal review found that the state’s MFCU was in “general compliance” with federal requirements. But it also found that the fraud unit was receiving few referrals of potential cases from the Department of Social Services, which administers Medicaid.

South Dakota State Medicaid Fraud Control Unit 2016 Onsite Review by Beverly Tran on Scribd

Each time a kid is snatched from the family for the crime of poverty, another state child welfare contractual arm cashes a check drawn off Medicaid.

Whether the snatching is legitimate or not, does not matter, because the States Medicaid Fraud Control Units will never, ever, receive referrals of fraudulent billing in child welfare.

Aho.

OGLALA SIOUX TRIBE V. VAN HUNNIK - SUMMARY JUDGMENT on ICWA and Child Protective Services by Beverly Tran on Scribd

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