Among the cases was one involving Sparta personal care service providers. The two face 46 months in prison and $620,000 in fines.
“Medicaid cheaters rob taxpayers, hurt needy patients and push medical costs higher for all of us,” Cooper said. “We’re stopping the waste and abuse and making violators pay.”
“This is what we meant when we pledged to set government straight – eliminating waste and making government work more efficiently for the people of North Carolina,” said Gov. Bev Perdue.
During the federal fiscal year that ended September 30, 2010, Cooper’s Medicaid Investigations Unit prosecuted 22 criminal convictions and 18 civil settlements that recovered $53,529,270.49 from Medicaid abusers. Several of those cases started with referrals to Cooper’s office by the Department of Health and Human Services, which identified tens of millions of dollars in possible overpayments and waste in the system.
These latest successes at rooting out fraud build upon several years of record-setting recoveries. The Medicaid Investigations Unit (MIU) has recouped more than $400 million over the past decade and helped to convict more than 450 individuals on criminal charges including patient abuse and neglect as well as financial fraud.
North Carolina’s MIU will expand its focus on waste and abuse, particularly on community service providers that commit fraud. The most recent state budget approved by the legislature included 25 new Medicaid fraud attorneys and investigators for the N.C. Department of Justice at the Governor’s request, nearly doubling the unit in size. The Department is currently in the process of filling those new positions.
Medicaid is a joint federal-state program that provides health insurance for the poor.
The following cases from the 2010 fiscal year illustrate how the MIU seeks to win back taxpayer money and punish wrongdoers:
In the largest single recovery of the year, drug maker Pfizer paid $25.5 million to North Carolina in November 2009 to resolve charges that the company cheated the state’s Medicaid program. The MIU alleged that Pfizer paid illegal kickbacks and marketed drugs for unapproved uses in order to sell more of certain drugs, including Bextra, Geodon, Zyvox, and Lyrica.
The MIU recovered nearly $1.9 million from a mental health provider in Fayetteville and Dunn that fabricated and forged records to overcharge Medicaid and Tricare, a program that provides health insurance to members of the U.S. military and their families. Following a joint investigation and prosecution with the MIU, the Defense Criminal Investigative Service, and the United States Attorney’s Office for the Eastern District of North Carolina, Sandra Elliott, owner of Learning Links, pleaded guilty in January 2010 to health care fraud and aiding and abetting fraud. She was sentenced to 120 months in federal prison to be followed by three years of probation.
Acting on an anonymous tip and information provided by the Division of Medical Assistance/Program Integrity Section, MIU investigators discovered that a personal care services provider in Sparta had submitted numerous false claims for Medicaid reimbursement, including claims for a patient who was deceased and for another who had moved several hundred miles away. In a joint prosecution by the MIU and United States Attorney’s Office for the Western District of North Carolina, owners Kristie Brake and Kimberly Miles pleaded guilty to fraud in federal court in December 2010 and were sentenced to 46 months in prison and three years of probation plus more than $620,000 in fines.
The MIU aggressively investigates fraud and abuse of Medicaid benefits by hospitals, doctors, pharmaceutical companies, medical equipment companies, mental health and personal care providers, ambulance services and others, and also investigates patient abuse and neglect in nursing homes and other Medicaid-funded facilities. The unit includes attorneys, investigators and State Bureau of Investigation agents who work closely with United States Attorneys, District Attorneys, and other Federal and State law enforcement agencies.
“Our attorneys and investigators will keep up their work in the year ahead to uncover health care fraud and hold violators responsible,” Cooper said.
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