Medicaid fraud


The Living Force
I'm not sure if this article belongs here but it's about Medicaid "fraud".

I'm on Medicare and Medicaid Health Insurance, due to - lower income bracket and services are at a bare minimum. Just to get a simple blood test and depending on what the Doctor ordered, can be a problem, if extra testing is needed. There's the standard health screening (temp, pressure including visit) and any other testing is scrutinized by the Health Insurance provider, which can take up to a week or more, for approval in a non-threatening setting. In some cases, testing is modified. Instead of a suggested MRI - X-rays or muscle testing by a Neurologist will be ordered - to reduce cost. From the initial Doctor's visit, approval of testing or alternate, to setting up appointments and getting testing done, could entail 3-4 weeks and another week or so for results - before another visit to the Doctor can be set up. Prescriptions are another problem if the Doctor prescribes a brand name. The Pharmacy will try to match a "generic" as a substitute and if none exist, a call is placed to the Doctor's Office and another variation is ordered. In the end, you have health coverage but in principle, it does little to help in a real medical emergency. If Medicaid doesn't cover "the full testing" ordered by the Doctor, his Staff will suggest a visit to the local Hospital "Billing Dept." to set up a payment plan - for your out-of-pocket expenses.

My experiences with Medicare and Medicaid, in the last 5-6 years, have me to the point, I have to weight my options - if I can financially afford to go to the Doctor's?

Now and then, I read cases on Medicaid fraud in the news. This one tipped the scales! They pay a small "fine" which probably doesn't even cover a percentage of the full amount extracted in the fraud and no one is held accountable or goes to jail? If I miss a payment, by a few days pass the due date, the "Hospital's Billing Dept." contacts me with threatening phone calls and mail notifications - that I can be fined or imprisoned - due to not receiving my Fifty-three dollars payment on time! They offer - no grace period - in the event, a SS Check is late in the mail. Thank Gawd, it only happened "once" and I finally paid off the Bill.

NY Jewish charity admits to Medicaid fraud, agrees to pay $47M

January 21, 2016 - NEW YORK (JTA) — A Jewish health care charity accused of Medicaid fraud has agreed to repay $47 million to the U.S. and New York state governments.

CenterLight Healthcare, formerly called Beth Abraham Family of Health Services, admitted in a settlement to having over 1,000 ineligible members in its Medicaid-sponsored long-term care plan, the Forward reported Thursday.

CenterLight is a member of UJA-Federation of New York’s network of agencies and received $84,000 from the federation in the current fiscal year, according to the Forward. UJA-Federation and CenterLight declined to comment on the settlement.

According to the Forward, CenterLight’s auditor, Loeb & Troper, including FEGS, which filed for bankruptcy last year. In statements issued by New York State Attorney General Eric Schneiderman and U.S. Attorney Preet Bharara, CenterLight acknowledged in the settlement that 1,241 people referred to its Medicaid plan were either ineligible when they enrolled or were not removed after they became ineligible.


The Living Force
The Affordable Care Act, a.k.a. Obamacare isn't any better than Medicare or Medicaid in providing any proper "affordable" health screening, testing, diagnosis and treatment.

Jonathan Gruber, an MIT professor and the architect behind the Obamacare Law is now admitting the fact, that Obamacare imposes massive taxes on benefits. Gruber is now being investigated for possible - ‘Phantom Billing’ and Tax Reporting - for an estimated $5 million he earned over the past four years in Federal and State contracts.

Obama deliberately worked to deceive Americans about healthcare law, Gruber interview reveals

In recent weeks, video after video has surfaced of Gruber explaining what avenues of deceit had to be traveled in order to fool the public into thinking that the law was something that a) needed to be done to save American healthcare; and b) would accomplish several things at once, such as lowering overall costs while allowing Americans to keep their doctors and their plans.

In this video clip, for instance, Gruber explains how he and Obama schemed to hide the fact that Obamacare imposed massive taxes on benefits:

The thing that is real cost control, that we know it'll work, go after this. Now the problem is, it's a political nightmare. And people say, "No, you can't tax my benefits." ... So, what we did a lot in that room [at the White House] [was] talk about... well, how could we make this work? And Obama's like, "Well, you know..." -- I mean, he's a really realistic guy -- he's like, "I can't just do this. It's just not gonna happen politically. The bill will not pass. How do we manage to get there through phase-ins and other things?" And we talked about it. Um... and he was just very interested in that topic. That ultimately became the genesis of what's called the "Cadillac tax" in the healthcare bill, which I think is one of the most important and bravest parts of the healthcare law...

That frank discussion led the president to -- as usual -- issue a blanket denial. No, he assures us, there was no scheming going on to get his signature healthcare law passed -- this is from a man who lied repeatedly about virtually every aspect of it, including insisting early and often that, no, the individual mandate wasn't a "tax" (the U.S. Supreme Court said otherwise, though that, too, is another story).

In a follow-up interview with Fox News' Bill O'Reilly, columnist, author and political analyst Dr. Charles Krauthammer said that "liberal arrogance" was in play -- and that those on that side of the political aisle really do "believe that the voters are stupid" and have to be led to certain policy decisions.

"That's what [Gruber] said openly," Krauthammer said. "We wanted to get the bill, we didn't care how we did it, so we lied about everything. We lied about if you can keep the plan, knowing that you can't keep your plan. We lied about the fact that this would be a transfer of wealth, a massive transfer of wealth, because as Gruber said, had [the American people] known that, [Obamacare] would never have passed. They lied about every aspect of this, and I think that is what has been charged all along."

He also said it was "a scandal of the media that this has to be discovered in the sixth year of the presidency, rather than talked about at the time, when it was obvious they were lying about all this. ... But, they got away with it."

Jonathan Gruber Faces Questions About ‘Phantom Billing’ and Tax Reporting

26 Jan 2015 - Vermont State Auditor Doug Hoffer is not the only one raising questions about Jonathan Gruber’s billing practices.

On Monday Darcie Johnston, head of Vermonters for Health Care Freedom, told Breitbart News that Gruber may have a “phantom billing” problem.

“Jonathan Gruber has failed to provide any evidence that the $80,000 he’s been paid by the state of Vermont for 800 hours of work he claimed was performed by unidentified research assistants was actually performed, or that these research assistants even exist and were paid,” Johnston told Breitbart News.

“There’s a term in health care for the practice of billing for services not provided. It’s called ‘phantom billing,’ and when doctors or health care providers do this, they face criminal charges.”

Johnston’s comment expands the potential number of legal problems which Gruber may face in connection with his lucrative consulting business, from which he earned an estimated $5 million over the past four years in federal and state contracts.

On Friday, white collar criminal defense attorney Brady Toensing told Breitbart News, “if [an] investigation uncovers sufficient evidence that Gruber padded his bills, he could be charged by the state with contract fraud or by the feds with mail or wire fraud.”

Gruber could also potentially face legal troubles under the federal False Claims Act, which allows whistleblowers to file lawsuits as “qui tam” plaintiffs against individuals or corporations that have defrauded the federal government.

To date, Vermont State Auditor Doug Hoffer’s inquiry has not addressed the possibility that Gruber’s receipt of $80,000 for work he claims was done by research assistants may be “phantom billing.”

Hoffer has asked for only the minimal information from Gruber about his research assistants: their names, employment status, and contact information. Gruber has refused to provide this information.

Though Gruber has failed to respond to Hoffer’s information requests to date, Hoffer has subpoena power and could subpoena all of Gruber’s business documents, bank statements, and financial records related to his contract with the state of Vermont. While enforcement of that subpoena would require the cooperation of the Democratic Attorney General of Massachusetts, Maura Healey, the documents it uncovers could turn up a hornet’s nest of trouble for Gruber.

Healey was elected to her first term as Attorney General of Massachusetts in November, defeating Republican nominee John Miller by a 62% to 38% margin, and was sworn in early this month. On Monday Breitbart News asked a spokesperson if the Attorney General’s office would enforce a subpoena in Massachusetts issued by Vermont State Auditor Hoffer for Gruber’s records.

Breitbart News has yet to receive a response to that request.

As part of his inquiry, Hoffer could subpoena Gruber to provide copies of the 1099s or W-2s he provided his research assistants for work performed by them on the state of Vermont contract in 2014. Under federal law, the Internal Revenue Service requires that all employers provide independent contractors who have worked for them in 2014 with 1099s and employees who have worked for them in 2014 with W-2s by January 31, 2015. (This year, that deadline is extended to February 2, 2015, since January 31 is a Saturday.)

Vermont State Auditor Hoffer’s request for information on the employment status of the research assistants Gruber claimed conducted work under his supervision is relevant to the issue of Gruber’s tax reporting responsibilities.

If those research assistants are independent contractors, Gruber’s only tax reporting obligation is to provide them with 1099s, and include copies of those 1099s in his own personal tax filings for 2014.

If, however, the research assistants were employees, Gruber is responsible for paying Social Security and Medicare withholding taxes as well as providing them with W-2 forms. While Gruber may be an internationally prominent economist with an extensive academic pedigree, his record as a businessman is filled with questions about his billing practices, sloppy bookkeeping, and failure to incorporate his consulting activities into a separate business.

Based on all evidence currently available to Breitbart News, the $5 million Gruber received over the past four years from federal and state governments contracts was paid to Gruber personally, rather than to a corporate entity. Consultants often establish separate corporate entities to prevent co-mingling of funds and allow for clean record keeping, particularly as it relates to federal and state tax payment and reporting.

While it is a common practice and entirely legal for an individual who operates a small consulting business to operate it as a proprietorship rather than to form a corporate entity from which to operate it, it is unusual to operate a consulting business on the scale of Gruber’s without forming a separate corporate entity.

Operating a consulting business of the size of Gruber’s enterprise as a proprietorship run out of a personal bank account can be a tax and record keeping nightmare.

On Friday, Breitbart News confirmed with the office of Massachusetts Secretary of State William Galvin that Gruber, a resident of that state, has not formed a corporate entity of any sort there.

In addition to the state of Vermont, the state of Minnesota, the House Government Oversight and Reform Committee have confirmed and the Inspector General’s Office of the Department of Health and Human Services is considering conducting inquiries into Gruber’s billing practices and consulting contracts.

To date, there are no press reports indicating that any one in the Department of Justice or the Internal Revenue Service is investigating Gruber’s contracts and billing practices.

With regards to qui tam plaintiff claims under the federal False Claims Act, such claims could potentially be brought in connection with Gruber’s 2009 contract with the Department of Health and Human Services for $392,600, where, as Breitbart News has documented, at least one of his research assistants was paid by the National Bureau of Economic Research (which was not party to the contract), rather than by Gruber himself.

In the case of Gruber’s state contracts, a federal False Claims Act suit from a whistleblower would face a higher hurdle, unless the qui tam plaintiff could prove that the state contract was funded substantially by a grant from the federal government.


Padawan Learner
Hi angelburst29,

I sorry don't have any solutions for you. Just some commiseration and a few comments.

The economy has been in serial bubble/ponzi/pyramid mode for some time. Just going back to the 80s we've had junk bonds, S&L crisis/bailouts, regional housing bubbles, bubble, prolific war/security spending, a nationwide housing bubble, and bank/financial bailouts, all the while hollowing out and stripping of everything folks need to live a decent life.

With all the above done, it was time to find another extraction/rent-seeking endeavor, and "health care" came up on the board. It is the only sector that has shown any "growth" lately so it is successful as far as that goes in accounting for growth in published GDP, and that is the most important thing. It was never to help anyone. :(


The Living Force
FOTCM Member
From the provider end, at least in my state, Medicaid is very difficult to work with. The constraints are downright ridiculous. We get only $2 for a set of X-rays, not enough to even cover cost. The sad thing to me is that these constraints always fail to control costs. The situation is that as very few things are covered care and reimbursement is iffy at best, so fewer and fewer providers participate. The result is that needed care gets shifted to highest cost ERs. Very sad for everyone.
I think patients/recipients are generally very surprised by the reality.
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