Sweet Home Alabama

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Calculator and stethoscope on paperwork

Medicaid is a state-run insurance program intended to help individuals and families afford health insurance when they may not otherwise be able to. The Medicaid program is also seen as a lucrative target for fraudsters looking to defraud government programs for their own benefit.

An Alabama woman recently pleaded guilty for defrauding the Alabama Medicaid program out of $1.5 million dollars. Heidi Robertson abused her position as a primary insurance biller at a psychology clinic so she could charge Medicaid for services never provided.

Robertson filed false claims to the Alabama Medicaid Agency while she was employed at Capstone Medical Resources LLC from 2016 to 2017. Capstone was approved by the Alabama Medicaid Agency to provide individual and group counselling services for at-risk youths. The owner of the group, psychologist Shaon Waltz, pleaded guilty for her role in the scheme in 2019.

The Program Integrity Division of the Alabama Medicaid Agency launched an investigation after an audit revealed that Capstone’s billings increased by more than $2 million from 2015 to 2017. (That’s more than just having a lucky break.)  

Capstone submitted fictitious records during this audit, at which point the Attorney General’s Medicaid Fraud Control Unit stepped in to continue the investigation. (Capstone committed more crimes in an attempt to get away with the crimes they already committed.)  

The Medicaid Fraud Control Unit determined that the majority of claims Capstone submitted from 2016 to 2018 were fraudulent. Robertson filed Medicaid claims for services that never occurred by submitting the names of friends, family members, and their children. Waltz paid Robertson a 10 percent commission for every claim paid by Medicaid. (An incentive for doing the wrong thing.)

Those involved in the Capstone scheme attempted to profit at the expense of at-risk youths they were entrusted to provide psychological services to. (These youths probably didn’t realize they were ‘at-risk’ of being defrauded by their local clinic.)  

In total, the Alabama Medicaid Agency was defrauded of more than $1.5 million dollars between 2016 and 2018 as a result of this illegal scheme. Robertson pleaded guilty to one count of conspiracy to commit healthcare fraud and was sentenced to 18 months in prison and ordered to pay $850,000 in restitution.

The Department of Justice relies on its federal and state partners as well as tips from the public to detect and prosecute Medicad fraud. Suspected Medicaid fraud can be reported by phone at 1-800-447-8477 or via email to HHSTips@oig.hhs.gov.

Today’s Fraud of the Day comes from a Department of Justice Press Release , “Former Employee of Birmingham Area Psychology Clinic Sentenced for Role in Defraudinsg State Medicaid Agency of at Least $1.5 Million,” published on November 17, 2020.

BIRMINGHAM, Ala. – U.S. Attorney Prim Escalona, Alabama Attorney General Steve Marshall, and U.S. Department of Health and Human Services -OIG Special Agent in Charge Derrick Jackson announced the sentencing today of a woman for her role in a scheme to defraud the Alabama Medicaid Agency of at least $1.5 million. Heidi Robertson, 35, was employed as the primary insurance biller at a Birmingham-area psychology clinic that billed the Medicaid Agency for counseling services that were never provided.

Robertson was sentenced to 18 months in prison and ordered to pay $850,000 in restitution by U.S. District Judge R. David Proctor after she pleaded guilty earlier this year to one count of conspiracy to commit healthcare fraud by filing false claims to the Alabama Medicaid Agency for individual and group counseling services for at-risk youth while she was employed at Capstone Medical Resources LLC.  The owner of the facility, former Birmingham psychologist Sharon D. Waltz, pleaded guilty in 2019 to defrauding Medicaid of at least $1.5 million. Waltz is scheduled to be sentenced by Judge Proctor on December 10.

 

 

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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.