NEW YORK STATE MEDICAID FRAUD CONTROL UNIT Eric T. Schneiderman Attorney General of the State of New York

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1 NEW YORK STATE MEDICAID FRAUD CONTROL UNIT Eric T. Schneiderman Attorney General of the State of New York Jennifer M. Sommers Special Assistant Attorney General

2 Medicaid Fraud Control Unit Created in 1975 as a result of abuses in the nursing home industry. Federal legislation creating the state MFCUs. Under the AG s Office Team concept for fighting fraud: Attorneys Auditors Investigators Separate and distinct from Dept of Health, OMIG

3 OUR FEDERAL MANDATE To investigate and prosecute criminal acts of Medicaid Fraud; To investigate and prosecute criminal acts of patient abuse and neglect; To seek the recovery of Medicaid overpayments.

4 Trends in Long-term / Sub-Acute care. Nursing Homes / Long-term care facilities Adult Day Care Facilities

5 Fraud Related to Prescription Drug Abuse Prescription drug abuse has become so pervasive that the Centers for Disease Control and Prevention has formally labeled it an "epidemic." One in four teens has misused or abused a prescription (Rx) drug at least once 33 # increase since Approximately four of five new heroin addicts became addicted to prescription pills before ever taking heroin.

6 Drug Diversion The redirection of prescription drugs for illegitimate purposes. According to the Office of Inspector General investigations of drug diversion are on the rise. A contributing factor may be that this type of fraud can be very lucrative. Drug seekers Drug providers

7 Drug Diversion Examples: Selling Prescription Drugs; Doctor Shopping; **Drug Theft (anywhere in the chain)**; Prescription Pad Theft and Forgery; Over Prescribing. **Primary drug diversion issue with long term care**

8 Sub-Acute Care / Elderly Patients Perfect Population to Exploit This population is commonly prescribed narcotic pain relievers (Oxycodone / Vicodin / etc.) as well as anti-anxiety medications (Ativan / Valium /etc.). Regular and more importantly PRN (as needed). Memory issues. Commonly complain of pain. Very easy to manipulate their records.

9 Methods of Prescription Drug Diversion Fraud Persons with access to the drugs divert them from the patient; Records (Narcotics Log, MARS, are often falsified). The patient is either NOT given any drug (may not have requested any) or is given a sham drug - not the one prescribed and requested / needed. Potential crimes Falsifying Business Records, Reckless Endangerment, Endangering the Welfare of an Elderly Vulnerable Person.

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12 Preventative Steps Examine the procedure for keeping and disseminating controlled substances; Consider two person disseminations; Audit for unusual circumstances; Nurse Jones is the only nurse who routinely provides patient X with PRN narcotics. Nurse Jones is the only nurse who wastes. Any type of change in MARS, Narco Logs. and/or waste drugs.

13 Fraud Related To: Elder Abuse / Neglect Typical scenario : MARS / TARS will require a particular procedure / administration of medication, etc.; Nurse / Aide / etc. Med Tech will not properly provide the service; Nurse / Aide will falsify the MARS / TARS to conceal the neglect.

14 Example: Patient X s care plan: Requires that his blood pressure be measured before hypertension medicine is administered; Requires that glaucoma medication be administered by eye drops 2x a.m. and 2x p.m.; and All transfers be with a Hoyer mechanical lift. Nurse Jones Does not measure the BP before administering hypertension 10/10 days that she works and does not administer the eye drops. Aide Smith transfers the patient alone without using a lift. MARS / TARS are completed as if all tasks were performed properly.

15 How Do We Know?

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17 Hidden Camera Cases Patient Specific. Care Plan is reviewed; Camera installed with the patient / patient s family s permission; Care is monitored; Paperwork completed during the duration of the camera s operation is secured and compared with the care that was captured on video.

18 Camera Compared with MARS

19 How Do We Know? Whistleblowers.

20 Implications for Caregivers AND Facilities Caregivers Criminal Liability, Licensure Issues, Exclusion from the Medicaid Program Facilities Bad Press as well as potential civil lawsuits and (potentially) criminal liability. Civil Medicaid payments made for submitted claims assume that proper care was provided. Criminal If individuals in supervisory roles are aware of false, fraudulent claims, or attempt to cover up misconduct, they can also be held liable.

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23 Medford Case Civil and Criminal (Whistleblower Case)

24 Criminal Charges Background 72 year old female, temporarily in nursing home for rehabilitation. Had pneumonia and needed to be connected to a ventilator at night. Allegations only Presumption of Innocence. Kethlie Joseph - Licensed respiratory therapist, never read the doctor s orders requiring the resident to be connected to a ventilator machine at night. Resident was not connected to the ventilator when she went to sleep and she died that night. Ignored alarms for more than two hours, as well as messages to her pager when the resident stopped breathing. Video surveillance also captured Joseph walking toward her office and passing the resident s room while the alarms were sounding.

25 Marianne Fassino RN who was in charge of the home s ventilator unit the night of the death and failed to respond to the visual and audio alarms for almost two hours despite being inches away from monitors. Leona Gordon - Aide who was responsible for watching the unit s alarm monitor in the nursing station to ensure that any alarms were answered in a timely manner. Kimberly Lappe - RN who also failed to respond to the visual and audio alarms for almost two hours. Despite video evidence to the contrary, Lappe falsely claimed in notes written a day after the incident that nurses responded to the alarms and that the resident was in stable condition. Victoria Caldwell LPN who falsely claimed to investigators that the resident was alive and looked up at me when in fact the resident had likely been dead for some time.

26 Christina Corelli - Aide who falsely claimed that the resident s respiratory alarms were not beeping and that the resident was breathing normally when she was in the room with the resident. Records show that the alarm system had been activated for the entire time she was in the resident s room. David Fielding - Medford Multicare Center s Licensed Administrator and Christine Boylan director of respiratory therapy were also indicted and charged with concealing computer records documenting the alarms that signified the resident s distress from the NYS Department of Health (DOH) during the course of its investigation, in an attempt to cover up the incident.

27 Civil Complaint Alleging corporate looting and fraud, based on a history of criminal conduct by employees of the home. Since 2008, an additional 17 licensed and certified employees of the Medford facility have been convicted of neglect and the falsification of records in an attempt to cover up abuse and neglect. [Hidden Camera Cases, etc.] The New York State Department of Health cited the nursing home for 130 violations of state regulations designed to ensure adequate care to nursing home residents. Five thousand incidents and accidents have been logged at the facility since 2008, averaging 20 per week; only 60 of the 5,000 were reported to the New York State Department of Health as required by law.

28 Civil Complaint Further Alleges: Even after all the arrests and citations, rather than investing in better staffing and improved supervision to remedy the history of neglect and inadequate care, the home s owners slashed salaries and supplies while paying themselves exorbitant salaries. 66 million dollars since 2003.

29 Fraud Related to: Adult Daycare Schemes: Billing Medicaid for non-reimbursable services. Non-qualified workers on staff while billing as if staffed appropriately. Other similar types of fraud as those seen in nursing homes.

30 The investigation, which included several undercover visits by a healthy and vibrant senior working on behalf of the Attorney General s Office, revealed that the facility was not providing services as represented in its claims for payment to Medicaid. The covert portion of the investigation captured on video two medical employees at Northern Manor ADHC, one of whom was a registered nurse, falsifying the healthy senior citizen s medical admissions forms to ensure he qualified for services that, in actuality, he was too healthy to receive. Further investigation uncovered that, in violation of state law, Northern Manor ADHC hired unqualified individuals to provide social work services, perform initial psychosocial assessments and diagnose the emotional and mental needs of registrants. State law requires a qualified social worker to perform these services.

31 Avoiding Issues in Long Term Care Understand the unique issues that this population presents Opportunities for exploitation. Invest in training, staffing, supplies, etc. Not only can this prevent issues up-front, but when issues do occur, institutions can be vulnerable if they are lacking in these areas. The cover up is generally worse than the crime. When incidents occur, report them honestly and without delay.

32 Questions???