Buried Under a Mountain of Paperwork

A brave little preschool age girl sits in her mother's lap at a table in the doctor's office. She opens her mouth wide for the nurse to swab her throat to check for strep.

Medicaid provider fraud is pretty common. It’s usually accomplished by submitting lots of claim forms stating that services were provided to beneficiaries, when they were not. Such is the case of a Troutdale, Virginia woman who was recently convicted of Medicaid fraud. She submitted more than 1,700 claims that were either fraudulent or missing supporting documentation. She was counting on the Virginia Medicaid program – Department of Medical Assistance Services (DMAS) – to not notice the discrepancies that were buried under a mountain of paperwork.

The Grayson County woman was employed as a Consumer Directed Services Facilitator (CDSF). Consumer directed services empower individuals with disabilities and older adults to have more control over the services they receive. The program is intended to let Medicaid beneficiaries assess their own needs, determine how and who meets those needs and they also monitor the quality of the services they receive. (That sounds like a pretty good deal, but it’s also easy to see how fraud can be committed within this program. If beneficiaries are unaware that claims are being submitted in their names, care providers can get away with collecting Medicaid benefits they don’t deserve.)

The CDSF from Troutdale was responsible for assisting elderly and disabled Medicaid beneficiaries. (Apparently, the only assistance provided was to her herself in collecting more than $100,000 from Medicaid.) Over seven years, the Virginian billed DMAS for 1,732 reassessments, routine visits and training. Many of these reassessments were not provided or they were missing supporting documentation to validate the claim. (Court records show that the deceptive provider had a habit of making copies of recipient’s signatures, then duplicating the forms.) In all, she fraudulently billed Medicaid for $121,435 and collected $113,877.

The 51-year-old pleaded guilty to Medicaid fraud. She was sentenced to four months behind bars and must pay full restitution of $113,877. It looks like while DMAS conquered the mountain of paperwork left behind by today’s fraudster, the Troutdale woman dug herself into a hole that might take some time to climb out of. Congratulations to Virginia’s Medicaid program for protecting the state’s vulnerable citizens by successfully halting this woman’s fraudulent billing scheme.

Today’s “Fraud of the Day” is based on a Department of Justice press release, “Grayson County Woman Sentenced for Health Care Fraud,” released on July 30, 2019.

Abingdon, VIRGINIA – Crystal Smith, a Troutdale, Va. woman who worked as a Consumer Directed Services Facilitator (CDSF) to assist elderly and disabled Virginia Medicaid recipients, was sentenced today to four months in prison and ordered to pay $113,877 in restitution. United States Attorney Thomas T. Cullen and Virginia Attorney General Mark R. Herring made the announcement today following Smith’s sentencing hearing in U.S. District Court in Abingdon.

“Medicaid providers, including those that provide home-based, education, and training services to disabled populations, are obligated to follow the letter of the law in billing for their work,” U.S. Attorney Cullen stated today.  “We will continue to prosecute those who engage in fraudulent billing schemes and hold them accountable.”

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Larry Benson
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.