Drug companies, health-care providers primary culprits in MaineCare fraud

Kathleen Sebelius, secretary of Health and Human Services, speaks at the 2012 Democratic National Convention about progress against Medicaid fraud.
Harry E. Walker | MCT
Kathleen Sebelius, secretary of Health and Human Services, speaks at the 2012 Democratic National Convention about progress against Medicaid fraud.
Posted Sept. 05, 2012, at 7:34 p.m.
Last modified Sept. 06, 2012, at 6:38 a.m.

The health care fraud investigators at the Maine attorney general’s office can rattle off the cases of some of the worst offenders from memory.

There’s the former provider convicted in 1995 of fraudulent billing who’s still paying monthly restitution 17 years later, $200 at a time. His debt to the state is now down to $20,000.

Then there’s Dawn Solomon, a Harrison woman who bilked MaineCare out of more than $4 million through her company that provided services for children with intellectual disabilities. She pleaded guilty in 2010 to overbilling for services and creating businesses solely for the purpose of fabricating invoices.

Solomon illustrates the damage one small health care provider can inflict, according to Michael Miller, head of a unit within the attorney general’s office that investigates health care crimes.

“Dawn Solomon will see my face more than once in her lifetime,” Miller said. “I will try to collect that money from her as long as I’m in this position.”

Abuse of public benefit programs in Maine often brings to mind recipients who lie to the state about their income or circumstances to unfairly gain access to services. But the bulk of the financial hit Maine suffers from health care fraud comes from health practitioners and drug companies tied into MaineCare, the state’s Medicaid program.

“A lot of our big numbers come from pharmaceutical companies who are doing what they’re not supposed to do, but even the small provider in Maine can do a significant amount of damage to the program,” Miller said.

From January 2010 to Sept. 5, 2012, Maine recovered nearly $40 million from civil fraud cases involving MaineCare providers. The state’s share was about $13 million, with the remainder returned to the federal government.

From criminal MaineCare fraud cases, such as Solomon’s, Maine recovered about $4 million in state and federal money over the same period.

Those millions resulted from fraud that government agencies rooted out, but much more is never even caught, Miller said.

Maine’s crackdown on health care fraud is part of a national effort. U.S. Health and Human Services Secretary Kathleen Sebelius, in a speech Tuesday at the Democratic National Convention in Charlotte, N.C., said the federal government has recovered a record $10.7 billion over the last three years from enforcement of health care and Medicare fraud.

The federal health reform law signed in 2010 by President Obama spelled out new enforcement measures, such as tougher sentences for health care fraud crimes, closer scrutiny of Medicare and Medicaid providers and suppliers, and better coordination among state and federal agencies, to prevent fraud.

Big-ticket national settlements from drug companies account for much of the money Maine has recovered, such as a 2010 agreement with British pharmaceutical company GlaxoSmithKline PLC over allegations that it knowingly manufactured and sold adulterated drugs, including the popular antidepressant Paxil. Maine’s share of the settlement totaled $1.8 million.

The cases also include providers that bill MaineCare for reimbursement for services that never were provided, such as a dentist getting paid for extracting the same tooth twice, Miller said.

“I’ve had cases where the provider was out of state or in jail and billing as if they were in a face-to-face counseling session” with a patient, she said.

Harder to catch but more common is “upcoding,” Miller said, where providers bill MaineCare for a greater share of services than they actually supplied. A Bangor psychologist pleaded guilty last week to engaging in sex acts with a client in his office and billing the sessions to MaineCare as therapy.

The financial impact of health care fraud is steepest among providers because the value of the services they wrongly bill for is high, Miller said. Fraud among recipients of MaineCare is also a serious problem, but criminal enforcement historically has been tougher in other programs within the Department of Health and Human Services, such as food stamps, said Assistant Attorney General Leanne Robbin.

From 2009 to 2011, Maine recovered about $80,000 in restitution from recipients of public assistance programs who were convicted of criminal fraud. That represented about a quarter of the $327,000 the state was owed.

Legislation enacted in May is aimed at rooting out those crimes, including instances of people unfairly taking advantage of MaineCare benefits, Robbin said.

“Health care is a real valuable item, and we are well aware of people who are above the poverty level making misrepresentations in order to get MaineCare benefits,” she said.

The state also has convened a work group that’s looking into health care fraud in Maine and has set up an online health fraud reporting form at www.maine.gov/dhhs/fraud/ and a hot line at 866-348-1129.

 

SEE COMMENTS →

ADVERTISEMENT | Grow your business
ADVERTISEMENT | Grow your business

Similar Articles

More in Health