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Senior Director of Strategic Alliances
LexisNexis Risk Solutions - Government

A Pikeville, Ky., man was sentenced to serve a lengthy 125 months in prison after being convicted in late 2021 of wire fraud and health care fraud. Eugene Sisco, III, 36, operated several medication assisted treatment (MAT) clinics in various counties across the state, offering treatment to patients suffering from opioid addiction.

Sisco’s clinics were enrolled as providers in the Kentucky Medicaid program. Under state law, they were required to bill Medicaid for MAT services rendered to eligible patients. (But Sisco didn’t pay any attention to that requirement.)

Sisco falsely claimed his clinics were not eligible to bill Medicaid for certain services provided. He used this ruse to trick patients into paying $200-$300 per month in cash for treatment at his clinics. Between May 2016 and October 2019, Sisco collected cash payments from unsuspecting patients totaling around $5 million. Most of these patients were Medicaid beneficiaries and the services they received should have cost nothing.

But wait, there’s more!  Not only was Sisco making big bucks from his patient’s cash payments, but he simultaneously billed Medicaid for MAT services, receiving millions in reimbursements from that program. (Can you say double dipping?) In addition, Sisco engaged in a health care fraud scheme. He used a similar ploy and caused his laboratory to bill for medically unnecessary urine drug testing of samples collected from patients at his clinics.

The fraudster caused a loss of more than $2 million to the Medicaid and Medicare programs. Sisco was ultimately ordered to pay $5.7 million in restitution and serve more than 12 years in prison. (Federal law says he must serve at least 85 percent of this sentence.) Following his release from prison, Sisco will be on probation for three years.

Today’s Fraud of the Day comes from a Department of Justice press release, “Pikeville Man Sentenced for Wire Fraud and Healthcare Fraud,” dated March 8, 2022.

PIKEVILLE, Ky.- Eugene Sisco, III, 36, of Pikeville, Ky., was sentenced Tuesday to serve 125 months in prison by U.S. District Judge Robert E. Wier, after a jury convicted him in November 2021 of wire fraud and health care fraud.

According to the trial evidence, Sisco operated several medication assisted treatment (“MAT”) clinics in Pike, Floyd, and Harlan Counties that offered treatment to patients suffering from opioid addiction.  These clinics were enrolled as providers in the Kentucky Medicaid program, and under Kentucky law were required to bill that insurance program for MAT services rendered to Medicaid patients.  The evidence demonstrated that Sisco deceived patients into paying $200-$300 per month in cash for treatment at his clinics, despite having Medicaid insurance, by falsely claiming his clinics were not eligible to bill Medicaid for certain services they provided.  The evidence at trial showed that the cash payments from patients totaled around $5 million between May 2016 and October 2019, most of it from Medicaid beneficiaries for whom the services should have cost nothing.  At the same time, Sisco caused his clinics to bill Medicaid for MAT services, receiving millions in reimbursements from that program as well.

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