The AG’s Medicaid Fraud Division investigates and prosecutes providers who defraud the state’s Medicaid program, MassHealth. The Division is also responsible for investigating complaints of abuse, neglect, mistreatment, and financial exploitation of patients in long-term care facilities and MassHealth members in all health care facilities.
In 2021, the Division entered into 22 civil settlements with various entities, including home health agencies, addiction treatment centers, adult day health centers, adult care providers, nursing homes qualified nurses and dental practices. The vast majority of Division recoveries were returned to MassHealth, but funds were also returned to the Department of Public Health’s Long-Term Care Facility Quality Improvement Fund; patients who paid out-of-pocket for services that should have been covered by MassHealth; the federal Medicare program; and whistleblowers who have sued vendors alleging fraud.
“I’m proud of the vital work our Medicaid Fraud Division is doing to protect our most vulnerable residents, safeguard taxpayer dollars, and maintain the integrity of the MassHealth program,” said AG Healey. “Combating fraud and misconduct in the healthcare sector is a top priority for my office, and we will continue this important work in 2022.”
Protect the physical and financial security of nursing home residents
The AG’s Medicaid Fraud Division continued to prioritize the physical and financial safety of Massachusetts nursing home residents in 2021. In September, a certified nursing assistant was charged with sexually assaulting two elderly residents nursing homes at Bear Hill Rehabilitation and Nursing Center in Stoneham and Knollwood. nursing center in Worcester while working night shifts.
In August, the former business office manager of Penacook Place Nursing Home in Haverhill pleaded guilty and was sentenced to prison for stealing tens of thousands of dollars from elderly residents. Similarly, in April, the former director of admissions at Meadow Green Nursing Home in Waltham pleaded guilty to participating in an embezzlement scheme to steal tens of thousands of dollars from an elderly resident.
The Division also reached settlements with the owners and operators of the Sweet Brook of Williamstown Rehabilitation and Nursing Center, which agreed to pay $110,000 to resolve allegations that it failed to adequately meet the needs and proper care of residents, and the operators of Brush Hill Care. Milton Center, which agreed to pay $90,000 to resolve allegations that it negligently cared for a resident, which resulted in the resident’s death, and that it did not complied with regulations requiring nurses to have adequate skills to care for residents in emergency situations.
Ensure high quality behavioral health services for MassHealth members
Safeguarding high-quality mental and behavioral health services for MassHealth members remained a priority for the Division last year. In October, in the largest settlement of its kind, a private equity firm and former executives of South Bay Mental Health Center, Inc. (SBMHC) agreed to pay $25 million for allegedly causing fraudulent claims to submit to MassHealth for mental health services provided. to patients by unlicensed, unqualified and poorly supervised staff in clinics across the state.
This settlement was the largest publicly disclosed government health care fraud settlement in the nation involving private equity oversight of health care providers, as well as the largest amount a private equity firm itself has agreed to pay to resolve fraud allegations involving healthcare holding companies.
It was also the largest Massachusetts settlement obtained by the Division and was in addition to the $4 million that SBMHC had already paid under a February 2018 settlement. Pursuant to this settlement, SBMHC also entered into a five-year compliance program overseen by an independent monitor to ensure that its clinics are fully compliant with MassHealth regulations and that all MassHealth patients would be seen by licensed, qualified and properly supervised personnel.
In November, the Division worked with the Office of Insurance Fraud to secure indictments against Nicole Kasimatis, owner and operator of Fortitude Counseling and Recovery Center in Quincy. After investigation, the Division alleged that Kasimatis billed MassHealth and private health insurers for substance use disorders and/or mental health services that she failed to provide either because she was incarcerated or outside the country; billed for services not performed by authorized or supervised employees of Fortitude; and billed for services under the name and number of service providers who no longer worked for Fortitude and who did not provide the services.
Fight against fraud in home services
The Division continued its longstanding work to combat fraud among home service providers. In December, a Chicopee-based home care company, Home Care VNA, agreed to reimburse $630,000 to resolve allegations that it had failed to comply with regulations requiring a doctor’s authorization for services. that she provided.
In November, a Brockton-based home care company, Independent at Home, and its owners agreed to repay $1.2 million and participate in a compliance program overseen by an independent monitor to resolve similar allegations. And a Lawrence-based home care company, Lifod Home Health Care, LLC, agreed to pay $1.25 million and implement an independent compliance monitoring program to resolve similar allegations in February.
Additionally, after securing indictments against seven people in a coordinated criminal roundup of fraud and abuse in the state’s Personal Care Attendant (PCA) program in October 2020, the Division has continued the prosecution of fraud in the PCA program, charging a New Bedford man in July who allegedly defrauded the program by falsely charging for services he did not receive.
Protect MassHealth from clinical lab self-referrals and unnecessary billing
The Division has also prioritized protecting MassHealth from unnecessary billing by clinical laboratories. In December, a nationwide chain of addiction treatment centers, Total Wellness Centers, LLC, CleanSlate Centers, Inc., and CleanSlate Centers, LLC (collectively, CleanSlate), agreed to pay a total of $4.5 million to MassHealth and Medicare to resolve allegations that the company submitted false claims for urine drug tests that were not medically necessary and were performed illegally in its own laboratory.
This resolution was the first civil settlement under Massachusetts’ clinical laboratory anti-self-referral law, originally proposed by the AG’s office. As part of the settlement, CleanSlate has also agreed to enter into an independent compliance program with annual audits that will be reported to the AG’s office.
The AG’s Medicaid Fraud Division maintained a national presence and leadership role in the National Association of Medicaid Fraud Control Units (NAMFCU) and its annual conference. Division chief Toby Unger is currently vice president of NAMFCU. The Division is also a national leader in policy and training initiatives as well as multi-state misrepresentation cases.
Medicaid is a multi-billion dollar joint state and federal program that provides health care coverage to economically disadvantaged people. The division works cooperatively with MassHealth and other state and federal agencies to prosecute provider fraud under the Massachusetts Medicaid program. Many cases handled by the AG’s office were referred by MassHealth, as well as state and federal agencies and law enforcement partners.
Medicaid’s Fraud Division receives 75% of its funding from the US Department of Health and Human Services through a grant. The remaining 25% is funded by the Commonwealth of Massachusetts.
