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DEPARTMENT OF JUSTICE CRIMINAL DIVISION MEDICAID FRAUD CONTROL UNIT Post Office Box 94005

DEPARTMENT OF JUSTICE CRIMINAL DIVISION MEDICAID FRAUD CONTROL UNIT Post Office Box 94005 Baton Rouge, Louisiana 70804-9005 Telephone: (225) 326-6210 Fax: (225) 326-6295 Attorney General Jeff Landry. PREVENTION & PROSECUTION OF RECIPIENT ABUSE and MEDICAID FRAUD.

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DEPARTMENT OF JUSTICE CRIMINAL DIVISION MEDICAID FRAUD CONTROL UNIT Post Office Box 94005

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  1. DEPARTMENT OF JUSTICE CRIMINAL DIVISION MEDICAID FRAUD CONTROL UNIT Post Office Box 94005 Baton Rouge, Louisiana 70804-9005 Telephone: (225) 326-6210 Fax: (225) 326-6295 Attorney General Jeff Landry PREVENTION & PROSECUTION OF RECIPIENT ABUSE and MEDICAID FRAUD

  2. MEDICAID FRAUD CONTROL UNIT • Is defined as ….‘a single identifiable entity of state government, annually certified by the Secretary of the US Department of Health and Human Services, that conducts a statewide program for • The investigation and prosecution of health care providers that defraud the Medicaid program. • Review complaints of abuse and neglect of nursing home residents and also may investigate complaints of misappropriation of patient funds in these facilities • Investigating fraud in the administration of the program’

  3. MEDICAID FRAUD CONTROL UNIT MEDICAID FRAUD CONTROL UNIT • Federal law requires each state to have an MFCU or provide a waiver to the Secretary of HHS • 50 states and the District of Columbia have MFCU’s • 43 MFCU’s are in the Office of Attorney General • 7 are in other state agencies such as State Police • MFCU must be independent of the state agency • No Medicaid agency has the authority to review Unit activities • No state Medicaid agency funds go to MFCU or vice versa • Every state Medicaid agency is required to have a formal agreement with the Unit that outlines each agency’s responsibilities and duties to one another

  4. MEDICAID FRAUD CONTROL UNIT MEDICAID FRAUD CONTROL UNIT • Staffed by Investigators, Auditors and Prosecutors • One or more attorneys with experience in the investigation and prosecution of civil or criminal fraud • Senior investigators with substantial experience in commercial or financial investigations • One or more experienced auditors capable of reviewing financial records • MUST work Medicaid matters exclusively

  5. MEDICAID FRAUD CONTROL UNIT LOUISIANA MEDICAID FRAUD CONTROL UNIT Established in 1978 • Staffed by: • Director • Chief Investigator • Supervisory Investigators • Forensic Nurse Investigators • Forensic Auditors • Forensic Computer Analysts • Prosecutors • Investigators • Support Staff • Total - 63 staff

  6. LOUISIANA MEDICAID FRAUD CONTROL UNIT LOUISIANA MEDICAID FRAUD CONTROL UNIT Federal Fiscal Year 2015 Statistics • 426 investigations • 356 fraud • 70 abuse and neglect • 91 indictments/charges • 84 fraud • 7 abuse and neglect • 73 convictions • 66 fraud • 7 abuse and neglect • 25 civil judgements and settlements Recovered $17,905,243.00 $5,072,526.00 criminal $12,832,717.00 civil

  7. What is Abuse? Abuse Can Be: • PHYSICAL • Hitting, slapping, pinching, punching • MENTAL • Threatening, scaring, intimidating • EMOTIONAL • Yelling, making cry • SEXUAL • Any inappropriate contact • FINANCIAL • Misuse of finances or resources

  8. In Louisiana, all these forms of abuse--whether physical, sexual, financial, or mental--are considered crimes, and any person who commits abuse can be prosecuted.

  9. Common signs of abuse include the following: (1) Bruises, cuts, welts, discoloration; (2) Dehydration and/or malnourishment without illness-related causes; (3) Fear, agitation, withdrawal, or depression; (4) Weight loss or other physical changes. Observe the patients under your care!!

  10. FACTORS CONTRIBUTING TO PATIENT ABUSE ABUSE JOB FRUSTRATION HIGH STRESS LOW WAGES STAFF PERSONAL PROBLEMS LOW STAFF RATIO LACK OF EMPATHY FOR ELDERLY INADEQUATE STAFF SUPERVISION MORE SEVERELY ILL RESIDENTS HIGH STAFF TURNOVER ABUSIVE OR BELLIGERENT PATIENTS LACK OF SKILLS TRAINING CULTURAL DIFFERENCES

  11. TOOLS OF THE TRADE, PART I: LOUISIANA LAWS GOVERNING PATIENT ABUSE

  12. False Imprisonment La R.S. 46 The intentional confinement or detention of another, without his consent and without proper legal authority. Fined not more than two hundred dollars and or imprisoned for not more than six months

  13. Criminal AbandonmentLa. R.S. 79.1 • Intentional abandonment • Aged (65 or older) or disabled person by paid caregiver • 1 year in jail and/or $1000 fine *This statute allows us to prosecute caregivers even when no injury occurs to the infirmed or disabled person

  14. Simple BatteryLa. R.S. 14:35 Simple battery is a battery committed without the consent of the victim Fined not more than five hundred dollars and/or imprisoned for not more than six months BRUISE

  15. Simple Battery of the Infirm La. R.S. 14:35.2 Battery committed upon Infirm Disabled Aged 6 months in jail and/or $500 fine

  16. Cruelty to the InfirmLa. R.S. 14:93.3 The intentional or criminally negligent mistreatment or neglect By any person, including a caregiver Whereby unjustifiable pain, malnourishment, or suffering is caused To the infirmed, a disabled adult, or an aged person

  17. Cruelty to the InfirmLa. R.S. 14:93.3 10 years in jail and/or $10,000 fine

  18. Sexual Battery of the InfirmLa R.S. 14:93.5 Engaging in sexual touching of genitals or anus Victim cannot resist due to advanced age or mental or physical infirmity 10 years in jail and/or $10,000 fine

  19. SIMPLE FORCIBLE AGGRAVATED RAPE HOMICIDE • NEGLIGENT • MANSLAUGHTER • MURDER

  20. The court in its discretion may sentence, in addition to any other penalty provided by law, any person who is convicted of a crime of violence or of an attempt to commit any of the crimes as defined in R.S. 14:2(B) with the exception of first degree murder (R.S. 14:30), second degree murder (R.S. 14:30.1), aggravated assault (R.S. 14:37), aggravated rape (R.S. 14:42) and aggravated kidnapping (R.S. 14:44), to an additional three years' imprisonment when the victim of such crime is sixty-five years of age or older at the time the crime is committed. Perpetration or attempted perpetration of certain crimes of violence against a victim sixty-five years of age or olderLA R.S. 14:50.2

  21. TheftLa R.S. 14:67 A. Theft is the misappropriation or taking of anything of value which belongs to another, either without the consent of the other to the misappropriation or taking, or by means of fraudulent conduct, practices, or representations. An intent to deprive the other permanently of whatever may be the subject of the misappropriation or taking is essential

  22. Property kept by the elderly may have little economic value…. But that property is likely to have a great personal value to the owner.

  23. Exploitation of the InfirmedLa. R.S. 93.4 Expenditure, Use, or Diminution of Assets or Property Of Disabled Adult, Infirmed or Aged Person OR Misuse of Infirmed Persons Power of Attorney 10 years in jail or $10,000 fine

  24. Identity TheftLa. R.S. 14:67.16 (a) Social security number (b) Driver's license number (c) Checking account number (d) Savings account number (e) Credit card number (f) Debit card number (g) Electronic identification number (h) Digital signatures (i) Birth certificate (j) Date of birth (k) Mother's maiden name (l) Armed forces identification number (m) Government issued identification number (n) Financial institution account number Personal identifying information shall include, but not be limited to, an individual's:

  25. Identity TheftLa. R.S. 14:67.16 • Intentional Use, Possession or Transfer • With fraudulent intent • Personal identifying information of another to obtain anything of value • Up to 10 years in jail pending and amount

  26. Theft of the Assets of An Aged or Disabled PersonLa. R.S. 14:67.21 • Intentional Use, Consumption, or Conversion of Aged or Disabled Person’s Assets • For benefit of another OR • Misuse of Power of Attorney of Aged or Disabled Person • For benefit of another • Up to 10 years in jail and/or $10000 fine • Offender can be ordered to pay full restitution

  27. TOOLS OF THE TRADE II LOUISIANA LAWS REGULATING CAREGIVERS

  28. Duty to Make ComplaintsLa. R.S. 40:2009.20 ANY Caregiver (this means YOU) Having knowledge that consumers physical or mental health Has been or will be affected by abuse MUST report to local law enforcement, DHH or MFCU within 24 hours 2 months in jail or $500 fine

  29. Non- Retaliation by Health Care ProviderLA. R.S. 40:2009.17 No discriminatory or retaliatory action shall be taken by any health care provider or government agency against any person or client by whom or for whom any communication was made to the department or unit, provided the communication is made in good faith for the purpose of aiding the office or unit to carry out its responsibilities. Any person who knowingly or willfully violates the provisions of this Section shall be guilty of a misdemeanor and upon conviction punished by a fine of not less than one hundred dollars nor more than five hundred dollars.

  30. Filing or Maintaining False Public RecordsLa. R.S. 14.133 A. Filing false public records is the filing or depositing for record in any public office or with any public official, or the maintaining as required by law, regulation, or rule, with knowledge of its falsity, of any of the following: (1) Any forged document. (2) Any wrongfully altered document. (3) Any document containing a false statement or false representation of a material fact. C. Whoever commits the crime of filing false public records shall be imprisoned for not more than five years with or without hard labor or shall be fined not more than five thousand dollars, or both.

  31. MEDICAID FRAUDLa. R.S. 70.1 • Intent to defraud the state through any medical assistance program • Presents for allowance or payment any false or fraudulent claim • Knowingly submits false information for the purpose of obtaining greater compensation than to which entitled • Knowingly submits false information for the purpose of obtaining authorization for furnishing services • Imprisoned with or without hard labor for not more than five years • May be fined no more than $20,000 • Both

  32. Forgery La R.S. 72 To forge with intent to defraud, any signature to, or any part of, any writing purporting to have legal efficacy. Can be theft from residents by forging checks Can be false documentation of medical records Penalty include 10 years jail time and five thousand dollar fine, per occurrence

  33. INVESTIGATIVE CRIMES When witnesses are threatened… When evidence is destroyed… When documents are altered…

  34. Obstruction of Justice La. R.S. 14:130.1 Tampering with evidence Threatening witnesses Retaliating against witnesses Up to 40 years in jail AND $100,000 fine

  35. REPORTING ABUSE and/or FRAUD

  36. Document Complaints/Instances WRITE REPORTS BE SPECIFIC BE CLEAR AND PRECISE BE COMPLETE SUPPORTING EVIDENCE

  37. Consequences of Committing Fraud and/or Abuse Immediate Termination Arrest and Prosecution Severe criminal penalties, including jail time and fines Loss of certification (LPN’s, RN’s, CNA’s, etc.) Exclusion from any healthcare provider/entity accepting state/federal insurance (Medicare/Medicaid/Tri-Care)

  38. Type name and search

  39. Unauthorized Participation in Medical Assistance ProgramsLA R.S. 14:126.3.1. • When the person has been excluded by any state or federal agency and knowingly: • Seeks, obtains, or maintains employment with a provider. • Seeks, obtains, or maintains employment as a provider. • Seeks, obtains, or retains any monies or payments derived in whole or in part from any state or federal medical assistance funds while excluded from participation in any state or federal medical assistance program. • Seeks, obtains, or maintains a contract with a provider. • Shares in the proceeds from a provider or participates in the ownership or management of a provider.

  40. Unauthorized Participation in Medical Assistance ProgramsLA R.S. 14:126.3.1. Imprisoned for not more than six months or fined not more than one thousand dollars, or both, when the state or federal exclusion is based on an underlying criminal conviction defined by Louisiana law as a misdemeanor, or when the exclusion is based on any reason other than a criminal conviction.

  41. TO REPORT FRAUD or ABUSE, CONTACT: Louisiana Attorney General Office Medicaid Fraud Control Unit 225-326-6210, M-F 8am – 5pm 888-799-6885, 24 hours a day 225-326-6295, fax 24 hours a day

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