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VOLUNTEERED: $285,000 BIG ONES
A Roxbury hospital has agreed to pay more than $250,000 in restitution to the state’s Medicaid Program, to perform community service and to accept tough compliance initiatives in order to resolve past billing problems.
A 1998 internal audit by the Jewish Memorial Hospital and Rehabilitation Center’s (JMHR) new administration found that previous employees had improperly altered certain Medicaid billing forms that allowed the hospital to receive payments for psychiatric services. JMHR, which was not authorized to bill Medicaid for such services, immediately conducted a thorough audit and voluntarily disclosed the problem to the Division of Medical Assistance.
During a period from January 1997 to February 1998, JMHA admitted 13 mentally retarded Medicaid members for inpatient treatment in the newly created behavioral unit. Under Medicaid provisions, inpatient psychiatric hospitalization services are covered by the Massachusetts
Behavioral Health Partnership (MBHP). As a managed care company, MBHP coordinates treatment for members with mental health and substance abuse diagnoses through a statewide network of inpatient hospitals. JMHA was not part of that network and was therefore ineligible to bill for hospitalizations.
Responding to orders from former members of the hospital’s management team, employees of JMHA’s billing department “whited out” certain diagnostic codes and replaced them with reimbursement codes before resubmitting the bills to Medicaid. Medicaid relied on the corrected claims and paid JMHA approximately $250,000.
In addition to $261,000 in cash restitution to the Medicaid Program, the settlement requires JMHA to perform $24,000 in community service. The hospital has agreed to hire a medical professional to provide free blood pressure and diabetes screening services in Roxbury in 52 sessions over the next 18 months. The screenings
will take place at supermarkets, senior, citizen centers and other locations. JMHA will advertise these services in local newspapers and on cable television.
Under the settlement, JMHA also agreed to new compliance enforcement initiates. For the next three years, the hospital must employ an independent Certified Public Accountant to audit the Medicaid billing practices and to submit an annual report to the Attorney General’s Medicaid Fraud Control Unit for review. The hospital also agreed to institute strict admissions screening standards to ensure that only Medicaid members with the appropriate diagnoses are admitted to the hospital for treatment. Current management fully cooperated with the investigation. Assistant AG Mark Muldoon and Senior Investigator Robert Russo of the Medicaid Fraud Control Unit handled the settlement and are conducting the ongoing investigation.
© 2000 John Cooke Fraud Report