Analyzing Healthcare Finance Fraud Case

Analyzing Healthcare Finance Fraud Case

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Real-time Healthcare Fraud News Report

The Healthcare compliance program is essential for an organization in ensuring it meets the ethical standards and operates within the set laws. A case in the Western District of Pennsylvania by the Department of Justice found a resident of Pittsburg, Tamika Adams guilty of conspiracy, aggravated identity fraud, and health care fraud. In the report released in March 2020, the resident was found guilty in a federal court with different counts of conspiracy to defraud the Pennsylvania Medicaid program, aggravated identity theft and health care fraud. This was announced by the United States Attorney Scott W. Brady before Judge Cathy Bissoon (U.S. Attorneys. 2020).

In the case, Adams was found guilty of participating in a wide-range conspiracy to swindle the Pennsylvania Medicaid program and obtain millions of dollars illegally through Medicaid payments. The fraud was done through Adams submitting fraudulent claims for medical services that were not provided to the persons identified in the claims. In other cases, there was fabricated or insufficient documentation that supported the claims. Adams admitted in the conspiracy that she fabricated timesheets to show that they had provided in-home personal assistance services that she never provided to the persons identified on timesheets (U.S. Attorneys. 2020).

Adams admitted to submitting false timesheets that claimed she provided at least 80 hours of care in a week and also worked full-time as a nominal president of ADI. She further admitted to having filled the submission of Medicaid claims with non-existent employees for PAS which never occurred. She also admitted to having paid kickbacks to a consumer in exchange for participation in the conspiracy. Adams together with co-defendant, Brown Tony, used the name of Brown on the timesheets to fabricate that Adam had indeed provided the care services. The proceeds received from the scheme were shared by the three people who were part of the conspiracy. In total, the Pennsylvania Medicaid program lost more than $250,000 in relation to the scheme (U.S. Attorneys. 2020).

Also, Adams admitted to having conspired and using her friend’s details, an employee of MCI to submit Medicaid claims for her for PAS care without her friend’s knowledge. This was provided to different consumers. These were false timesheet submissions as no such care was provided. In this case, Adams asserted that her friend had suffered a serious injury and was recovering and thus unable to work. Adams also used her friend’s PIN to access her information and use it falsely in the scheme. Finally, Adams admitted that in the course of audits of CCI, ADI, and MCI, she presented false documents in the submission to state agencies as part of concealing the Medicaid fraud conspiracy. Generally, Adams fabricated PAS timesheets, child abuse clearance systems for attendants, criminal history for attendants, and consumer affidavits to ensure the files requested in the audits were completed (U.S. Attorneys. 2020).

The investigations were swift and ensured every form and reports were thoroughly checked for credibility and in the end, the investigations revealed a conspiracy network that aimed at defrauding Medicaid millions of money. One key element that Adams lacked was ethics while the company she worked for had no comprehensive compliance program that ensured all employees ethically conducted activities and operations. The organization culture created by Adams was that of fraud as the cases were many. This means that after the first scenario where she obtained money falsely, she created a culture within the organization, that of fraud. This is what triggered an escalation of the fraud resulting in huge losses for the Pennsylvania Medicaid program. Creating an ethical culture in an organization is key in ensuring employees abide by certain standards.

Importune of Healthcare Finance Compliance Practices

Healthcare compliance in financial aspects is a continuous process adopted by an organization as part of ensuring it meets appropriate and acceptable legal, professional and ethical standards (HFMA. 2020). Healthcare organizations are required to develop effective processes, procedures and policies to define essential conduct, monitor adherence to guidelines, and provide education to employees on the standards required from them. Healthcare compliance in the area of finance captures of billing and reimbursement. The purpose of compliance programs in finance is meant to promote organizations’ adherence to set federal and state laws and payer healthcare requirements (HFMA. 2020). In the case above, Adams lacked ethics as she defrauded the Pennsylvania Medicaid program a couple of times. Even though companies are required to develop compliance programs as part of being enlisted in the Medicare program, the implementation of the compliance programs is key in ensuring compliance. As in the above scenario, Adams knew what was required of her in adhering to federal and state laws but provided false documents and submissions to gain from a fraud conspiracy.

Potential criminal and monetary fines that can be imposed on the individual and/or organization from the case.

The healthcare fraud and conspiracy charges carry a maximum sentence of 10 years imprisonment, or a fine of $250,000, or both. The fines for aggravated identity theft carry mandatory sentencing of 2 years imprisonment and run concurrently with any other sentence imposed on another charge and fine of not more than $250,000 (HHS 2020). According to Federal Sentencing Guidelines, the sentence imposed is based on the seriousness of the crime committed and any prior criminal history of the defendant if there is any. 

References

Healthcare Financial Management Association. (2020). Retrieved from https://www.hfma.org/

U.S. Attorneys. (2020) Western District of Pennsylvania. Retrieved from

https://www.justice.gov/usao-wdpa/pr/pittsburgh-resident-pleads-guilty-conspiracy-health-care-fraud-and-aggravated-identity

U.S Department of Health and Human Services. (2020) . Retrieved from https://www.hhs.gov/regulations/index.html

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