Altered State


An altered state of consciousness refers to someone in a mental state that is different from normal. (The phrase commonly means that the person is in a dream state or in a drug-induced trance that causes reduced alertness.) In today’s ”Fraud of the Day,” we focus on a nurse who created an altered state of a different kind. (She altered more than 50 patient medical records causing more than $875,000 in Medicaid reimbursements to be illegally funneled to her employer.)

The nurse, who was a former employee of a Medicaid Managed Care Organization (MCO) in Maryland, was part of a compliance team that electronically reviewed medical records remotely from her Florida home, then prepared documentation required for Medicaid reimbursement. She was investigated after multiple nurse supervisors discovered that some of the 792 medical records she had reviewed had been altered. (Maybe she was in her dream state when she was making changes to both paper and online patient medical records.)

The 61-year-old woman’s interference with patient records resulted in the distribution of incentive payments worth $875,279 to her former employer. (Further research discovered that the company could receive incentive payments from Medicaid if the business met defined health care benchmarks. I wonder if there was an employee bonus paid if these benchmarks were met. Fraudsters usually work hard for an incentive that involves cash.)

Although the woman was sentenced to five years in jail, her sentence was reduced to 18 months of home detention. She will also have supervised probation for three years and agreed not to work for a health care provider in a federally funded health care program for five years. The irony in this case is that the woman’s job responsibilities required her to comply with federal law. (Let’s hope she has awoken from her altered state of denial and now understands the ramifications of her selfish actions.)

Source: Today’s ”Fraud of the Day” is based on an article entitled, ”Former Priority Partners employee pleads guilty to Medicaid fraud,” published by The Baltimore Sun on August 26, 2016.

A former employee of Priority Partners, a Medicaid Managed Care Organization owned by Johns Hopkins HealthCare, pleaded guilty to felony Medicaid fraud for altering medical records that caused the Medicaid to improperly pay the company more than $875,000.

Inca Elfriede Schultz, 61, of Cudjoe Key, Fla., was sentenced to five years incarceration by Anne Arundel County Circuit Court Judge Michael Wachs. He suspended all but 18 months of her sentence to be served in home detention.

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Larry Benson is currently the Director of Strategic Alliances for Revenue Discovery and Recovery at LexisNexis Risk Solutions. In this role, Benson is responsible for developing partnerships for the tax and revenue and child support enforcement verticals. He focuses on embedded companies that have a need for third-party analytics to enhance their current offerings.