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Virginia Attorney General Health Care Fraud and Elder Abuse Section

Virginia Attorney General Health Care Fraud and Elder Abuse Section. Investigating and Prosecuting Health Care Fraud and Elder Abuse May 8, 2019 Nicole Terry Assistant Attorney General – Medicaid Fraud Control Unit. Overview. Who we are: History, Duty, and Capability

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Virginia Attorney General Health Care Fraud and Elder Abuse Section

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  1. Virginia Attorney GeneralHealth Care Fraud and Elder Abuse Section • Investigating and Prosecuting • Health Care Fraud and Elder Abuse • May 8, 2019 • Nicole Terry • Assistant Attorney General – Medicaid Fraud Control Unit

  2. Overview • Who we are: History, Duty, and Capability • How we work: Coordinated Investigations – FBI, HHS-OIG, IRS, Local Law Enforcement, DEA, VSP • What we’ve done: Abuse/Neglect; Health Care Fraud; False Statements; Alteration of Records; Agg. I.D. Theft; Prosecuting Abuse as Fraud Cases

  3. Who we are • In 1982, the General Assembly created the MFCU to investigate fraud and abuse committed against the Virginia Medicaid program. • “The unit will also review complaints alleging abuse or neglect of patients in health care facilities receiving payments under the State Medicaid plan and may review complaints of the misappropriation of patient’s private funds in such facilities.” 42 C.F.R.§ 1007.11(b)(1) • “[T]he Attorney General or his authorized representatives shall review complaints alleging abuse or neglect of persons in the care or custody of others who receive payments for providing health care services under the state plan for medical assistance.” Va. Code Ann. § 32.1-310

  4. Who we are • Approximately 47 full-time investigators • Two Nurse Investigators • Investigators with federal and state criminal investigative experience and former Adult Protective Services workers • Seven prosecutors and 14 civil attorneys • Four offices: Richmond; Fairfax; Roanoke; Abingdon • 2019 – Approximately 100 unit employees, three main components: • Criminal Provider fraud; Elder Abuse and Neglect; Civil Litigation.

  5. Who we are – what we investigate • Billing for services not performed • Billing for unnecessary services or tests • Embezzlement • Kickbacks • Inflating bills for services provided • Double-billing • Drug Diversion

  6. Who we are • Coordinated, multidisciplinary investigations • AG, Local law enforcement, VSP, USAO, FBI, HHS-OIG, DEA, FDA, IRS, Va. Tax, DMAS • 2014 Inspector General’s award for Excellence in Fighting Fraud, Waste, and Abuse • 2016-2017: 41 convictions; $19,551,281.05 in court-ordered civil and criminal recoveries • 2017-2018: 27 convictions; $14,112,278.09 in court-ordered civil and criminal recoveries

  7. Who we are • The Elder Abuse and Neglect Squad was formed in 2008. • The unit investigates single victim/single actor abuse and neglect of incapacitated adults committed by health care providers. • The unit also investigates corporate neglect in health care facilities.

  8. How we work – Identifying Relevant Material • Witness interviews Identifying potential witnesses: DMAS Audit; Provider contract; SCC records; Employment records; Licensing inspections; VDH nursing home inspections; DMV records; complainants • Medical records State regulatory inspections/audits Subpoena authority Audit and inspect authority • Billing history Number of patients Amount billed How long they have been a provider

  9. Criminal Case Studies • Fraud cases: • United States v. Deborah Branch, Bryan Harr Sr., and Melissa Harr • Drug Diversion cases: • United States v. Dwight Bailey MD

  10. Criminal Case Studies • United States v. Branch, B Harr, and M Harr • Referred to the MFCU by Bristol Department of Social Services • Personal and Respite Care for Evan Harr living with Cerebral Palsy and Kawasaki’s Disease, unable to communicate • Evan and his two younger brothers were kept locked in an upstairs bedroom- two mattresses on the floor, covered in feces, not light, no electricity, and the only window was broken by the boys attempt to escape • Evan’s Parents Bryan Sr. and Melissa convicted of three counts of cruelty to a child

  11. Criminal Case Studies • Branch and Harr (cont.) • Branch billed up to 12 hours per day for Evan’s care • Branch paid the parents $400 cash per month to sign the fraudulent timesheets • Medicaid paid $350,641.02 to the fiscal intermediary who then paid Branch $207,854.43 • All three pled guilty in federal court to Conspiracy to Commit Healthcare Fraud

  12. Criminal Case Studies • Branch and Harr (cont.) • Branch was sentenced to 72 month federal incarceration and three years probation • Bryan Harr Jr. was sentenced to 48 months federal incarceration to run consecutive with four years state incarceration and three years probation • Melissa Harr was sentenced to 48 month federal incarceration to run consecutive with three years state incarceration and three years probation • All defendants are responsible for $350,641.02 in restitution

  13. Criminal Case Studies • United States v. Dwight Bailey MD • Joint Investigation: MFCU, DEA, Virginia State Police • Bailey was prescribing drugs outside of the scope of a legitimate doctor-patient relationship • The Board of Medicine suspended Bailey’s license after finding Bailey to be a danger to the health and welfare of his patients and the public • The suspension was based on the treatment of nine patients who Bailey prescribed drugs • Five of the nine patients fatally overdosed between July 2010 and November 2011 • In August 2014 DEA, MFCU, and VSP executed a S/W at Bailey’s practice, office, and residence

  14. Criminal Case Studies • United States v. Dwight Bailey MD • After a lengthy trial Bailey was found guilty of 59 counts of Distribution of Controlled Substances, three counts of Conspiracy to Distribute Controlled Substances, and one count of Maintaining a Premise for the Purpose of Distribution of Controlled Substances • Bailey was sentenced to 151 months of federal incarceration, two years probation, ordered to pay $25,000 fine, and $6,300 special assessment

  15. Prosecuting Elder Abuse as Fraud Cases • Mixed results prosecuting cases as Abuse or Neglect of an Incapacitated Adult • The statute is cumbersome; tendency to not second-guess care givers • False Statements relating to health care matters • Health care fraud (10 year max penalty)– enhanced penalty: If the violation results in serious bodily injury … such person shall be fined under this title or imprisoned not more than 20 years, or both; and if the violation results in death, such person shall be fined under this title, or imprisoned for any term of years or for life, or both. • Still attack the injury or suffering – but approach the investigation and prosecution from a different perspective

  16. Summary • Who we are: History, Duty, and Capability • How we work: Coordinated Investigations – AG, Local Law Enforcement, VSP, FBI, HHS-OIG, DEA, FDA, IRS • What we’ve done: Abuse/Neglect; Health Care Fraud; False Statements; Alteration of Records; Agg. I.D. Theft; Prosecuting Abuse and Drug Diversion as Fraud Case

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