Massachusetts Medicaid Fraud Division Recovered More Than $55M In 2021

The AG's Medicaid Fraud Division investigates and prosecutes providers who defraud the state's Medicaid program, MassHealth. The Division is also responsible for reviewing complaints of abuse, neglect, mistreatment, and financial exploitation of patients in long-term care facilities and MassHealth members in any health care settings.

In 2021, the Division secured 22 civil settlements with various entities, including home health agencies, substance abuse treatment facilities, adult day health centers, adult foster care providers, skilled nursing facilities, and dental practices. The overwhelming majority of the Division's recoveries were returned to MassHealth, but funds were also returned to the Department of Public Health's Long-Term Care Facility Quality Improvement Fund; patients who had paid out-of-pocket for services that should have been covered by MassHealth; the federal Medicare program; and whistleblowers who brought lawsuits against providers alleging fraud.

"I'm proud of the vital work our Medicaid Fraud Division does to protect our most vulnerable residents, safeguard taxpayer dollars, and uphold the integrity of the MassHealth program," said AG Healey. "Addressing fraud and misconduct in the health care sector is a top priority for my office, and we will continue this important work in 2022."

Protecting the physical and financial safety of nursing home residents

The AG's Medicaid Fraud Division continued to prioritize the physical and financial security of residents in Massachusetts nursing homes in 2021. In September, a certified nursing assistant was charged with sexually assaulting two elderly nursing home residents at Bear Hill Rehabilitation and Nursing Center in Stoneham and Knollwood Nursing Center in Worcester while he worked overnight shifts.

In August, the former business office manager at Penacook Place Nursing Home in Haverhill pleaded guilty and was sentenced to jail in connection with stealing tens of thousands of dollars from elderly residents. Similarly, in April, the former admissions director at the Meadow Green Nursing Home in Waltham pleaded guilty to engaging in an embezzlement scheme to steal tens of thousands of dollars from an elderly resident.

The Division also secured settlements with the owners and operators of Sweet Brook of Williamstown Rehabilitation and Nursing Center, which agreed to pay $110,000 to resolve allegations that it failed to adequately meet the needs of and appropriately care for residents, and the operators of Brush Hill Care Center in Milton, which agreed to pay $90,000 to resolve allegations that it committed neglect of a resident, which resulted in the resident's death, and that it failed to comply with regulations requiring nursing staff to have adequate competencies to care for residents in emergency situations.

Ensuring high-quality behavioral health services for MassHealth members

Safeguarding high-quality mental and behavioral health services for MassHealth members remained a priority for the Division last year. In October, in the largest settlement of its kind, a private equity firm and former executives of South Bay Mental Health Center, Inc. (SBMHC) agreed to pay $25 million for allegedly causing fraudulent claims to be submitted to MassHealth for mental health services provided to patients by unlicensed, unqualified, and improperly supervised staff at clinics across the state.

This settlement was the largest publicly disclosed government health care fraud settlement in the nation involving private equity oversight of health care providers, as well as the largest amount a private equity company itself has agreed to pay to resolve fraud allegations involving health care portfolio companies.

It was also the biggest Massachusetts-only settlement obtained by the Division and was in addition to $4 million SBMHC had already paid pursuant to a February 2018 settlement. Per that agreement, SBMHC also entered into a five-year compliance program overseen by an independent monitor to ensure that its clinics came into full compliance with MassHealth regulations and that all MassHealth patients would be seen by licensed, qualified, and properly supervised staff.

In November, the Division worked with the Insurance Fraud Bureau to secure indictments against Nicole Kasimatis, the owner and operator of Fortitude Counseling and Recovery Center in Quincy. After investigation, the Division alleged that Kasimatis billed MassHealth and private health insurers for substance use disorder and/or mental health services she did not perform either because she was incarcerated or out of the country; billed for services not rendered by licensed or supervised Fortitude employees; and billed for services under the name and number of providers who no longer worked for Fortitude and who did not provide the services.

Combatting fraud in home-based services

The Division continued its longstanding work to combat fraud among providers who deliver home-based services. In December, a Chicopee-based home health company, Home Care VNA, agreed to pay back $630,000 to resolve allegations that it failed to comply with regulations requiring physician authorization for services it provided.

In November, a Brockton-based home health company, Independent at Home, and its owners agreed to pay back $1.2 million and enter into a compliance program overseen by an independent monitor to resolve similar allegations. And a Lawrence-based home health company, Lifod Home Health Care, LLC, agreed to pay $1.25 million and implement an independent compliance monitoring program to resolve similar allegations in February.

Moreover, after securing indictments against seven individuals in connection with a coordinated criminal sweep of fraud and abuse in the state's Personal Care Attendant (PCA) program in October 2020, the Division continued pursuing fraud in the PCA program, by indicting a New Bedford man in July who allegedly defrauded the program by falsely billing for services he did not receive.

Protecting MassHealth from clinical laboratory self-referrals and unnecessary billing

The Division also prioritized protecting MassHealth from unnecessary billing by clinical laboratories. In December, a national addiction treatment center chain, Total Wellness Centers, LLC, CleanSlate Centers, Inc., and CleanSlate Centers, LLC (collectively, CleanSlate), agreed to pay a total of $4.5 million to MassHealth and Medicare to resolve allegations that the company submitted false claims for urine drug tests that were medically unnecessary and were illegally performed at the company's own laboratory.

This resolution was the first civil settlement under the Massachusetts clinical laboratory anti-self-referral law, originally proposed by the AG's Office. As part of the settlement, CleanSlate also agreed to enter into an independent compliance program with annual audits that will be reported to the AG's Office.

The AG's Medicaid Fraud Division has maintained a national presence and leadership role within the National Association of Medicaid Fraud Control Units (NAMFCU) and its annual conference. The Chief of the Division, Toby Unger, is currently serving as the Vice President of NAMFCU. The Division is also a national leader in policy and training initiatives as well as in multistate false claims cases.

Medicaid is a multi-billion-dollar joint state and federal program that provides health care coverage for the economically disadvantaged. The Division works cooperatively with MassHealth and other state and federal agencies to prosecute provider fraud in the Massachusetts Medicaid program. Many of the cases handled by the AG's Office were referred by MassHealth, as well as state and federal agencies and law enforcement partners.

The Medicaid Fraud Division receives 75 percent of its funding from the U.S. Department of Health and Human Services under a grant award. The remaining 25 percent is funded by the Commonwealth of Massachusetts.