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Whistleblower: Clinics billed Medicaid for unlicensed treatment

A whistleblower has filed suit against a chain of Massachusetts mental health care centers, claiming the company defrauded the state and federal governments of $130 million. The accusation is that the company allowed "unlicensed, unqualified, and unsupervised employees" to treat patients. Doing so would be in clear violation of Medicaid regulations and requirements, the suit says.

The alleged misconduct was apparently widespread. The lawsuit claims that over 30,000 patients per year received treatment from unqualified clinicians at South Bay Mental Health Center, Inc. The company runs 17 mental health treatment centers in the state.

As a former training supervisor, the whistleblower appears to have been in a good position to know of the fraudulent billing.

The Massachusetts Attorney General's Office told WBUR that it is in the process of filing its own complaint against the company. South Bay's president and COO said that the company had reviewed the matter and its findings did not support the former employee's claims.

When a medical practitioner's credentials are falsely reported or exaggerated, a healthcare company may bill the government for a more expensive type of practitioner than was actually provided. For example, some practitioners are allowed to provide treatment, but only under the supervision of a licensed superior. These may have been billed at the same rate as practitioners who are qualified to act independently.

Whenever Medicare or Medicaid is falsely billed, it costs taxpayers money. How much is hard to pin down. Earlier this year, the Center for Public Integrity estimated that fraud and billing of Medicare and Medicare Advantage amounted to $60 billion in 2016.

If you work for a healthcare company that bills Medicare or Medicaid, you may be in a position to notice fraud. If you do, you could file a qui tam or False Claims Act lawsuit which, if successful, could result in a substantial reward.

Other common practices involving fraud against Medicare or Medicaid include:

  • Billing for services that were never provided
  • Billing for patients who were never treated
  • Providing unnecessary tests or treatments in order to bill for them, often in order to receive kickbacks
  • Double billing
  • Billing for more hours than were actually worked, or even more hours than there are in a day
  • Unbundling services in order to charge more
  • Upcoding -- billing for more expensive services than were actually provided
  • Referring patients to certain medical providers while concealing an ownership interest in those providers

Before you take any concrete steps toward blowing the whistle, it's a good idea to discuss your suspicions with a lawyer experienced in whistleblower claims. This can protect your rights as you determine your best way forward.

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