Anyone and Everyone

26146733 - disabled lady relaxed sitting in wheelchair in the garden

As of June 2018, more than 66 million individuals were enrolled in Medicaid. As approximately one-sixth of the national healthcare economy, it’s easy to see how the government healthcare program is an easy target for fraud. (In 2016, Medicaid spending totaled $565.5 billion.) A significant portion of fraud occurs when individuals providing personal care services submit fraudulent claims for services that were not provided. Today’s fraudster is a Lexington, Kentucky woman, who used her sister as a cover to commit Medicaid fraud. She submitted bills for $30,000 in personal care services she did not provide.

According to today’s article, many personal care services fraud cases get law enforcement’s attention from individuals who know the perpetrators are committing illegal acts. Such is true for our fraudster from Lexington. In the end, her whole family was involved in the court proceedings. (Let’s just say that it was a family affair and future family gatherings are likely to be tense.)

 The woman from Lexington served as a care giver for her adult sister, who was unable to speak and needed help with dressing, feeding and bathing. For approximately two years, she submitted bogus timesheets to Kentucky’s Medicaid Consumer Directed Option (CDO) program for services she never provided. (The CDO option is a program that allows patients to receive personal care services at home instead of in an institutional setting.)

The article does not state who tipped off the program, but an investigation into the matter was opened. Additional research shows that statements were taken from the caregiver’s parents. Another article stated that the caregiver had told her mom, “If we all tell the same thing, they’re not going to be able to prove anything.” (That turned out to be a very bad idea.) Unfortunately for the caregiver, the parents couldn’t get their stories straight and contradicted each other.

It was not helpful that her timesheets didn’t match up with vacation posts on Facebook, medical appointment records, surveillance and statements from two individuals who said she was elsewhere.

After a two-hour deliberation, the jury returned a verdict. The 40-year-old woman from Lexington, Kentucky was found guilty of Medicaid fraud. The jury also recommended five years behind bars when sentenced. Whatever the outcome is on sentencing, the real losers are the taxpayers who fund the program and the recipients who don’t get the care they qualify for and deserve. In this particular case, it was her own sister. (Fraudsters will use anyone and everyone to get what they want, even a vulnerable family member.)

Today’s “Fraud of the Day” is based on an article entitled, “Beshear: Lexington Woman Found Guilty of Stealing From State Medicaid Program,” posted on on March 5, 2018.

Attorney General Andy Beshear and his Office of Medicaid Fraud and Abuse today announced a Fayette County woman has been found guilty of taking more than $30,000 from the state’s Medicaid program.

A Fayette County jury found Amy Rector, 40, of Lexington, guilty on one count of Medicaid fraud, a Class D felony, and one count of theft by unlawful taking of property valued at $10,000 or more, a Class C felony. 

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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.