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8 charged for defrauding Massachusetts. Medicaid program

Eight people were charged Feb. 13 for allegedly defrauding MassHealth, the state Medicaid program for Massachusetts, of $260,000 by falsely billing for services not provided to them, officials said.

“MassHealth is a critical program that provides health insurance for some of our most vulnerable residents,” said Mass. Attorney Gen. Martha Coakley in a press release. “The brazenness of the fraud committed in these cases is particularly troubling. The defendants allegedly stole more than $260,000 from taxpayers, diverting resources from those who truly need it.”

The accused people include five former personal care attendants and three surrogates, including Amarilis Pirela, Marcy Keegan Grenache, Daniel Keegan, James Lynch, Holly-Beth Riopel, Abel Vega and Alan and Jacqueline Morrissette, according to the release.

Individuals are being charged for billing MassHealth for fraud schemes. In various instances the accused allegedly provided timesheets for someone who was incarcerated, someone who was out of the state and traveling extensively and charging for services for a person who was dead, according to the release.

Alec Loftus, communications director to the secretary of Health and Human Services, said PCAs are providers for someone in need of simple health care services, and the individual is able to choose a person to provide these services. If the individual is unable to pick their PCA, he or she may designate a surrogate to act on their behalf.

Loftus said the PCAs and surrogates are the ones who could commit fraud to the MassHealth program.

“MassHealth regularly looks for irregularities in its systems, and when MassHealth noticed these irregularities, we immediately referred them for investigation,” he said. “These programs are critical for helping those with disabilities and chronic illnesses who live independently in their communities. It’s sad when people try to take advantage of these people.”

Christopher Thompson, press secretary to the State Auditor, said the people accused were indicted in court last week and the court process is individual for each case.

In order to discover fraud in the state’s Medicaid system, MassHealth checks irregularities and generates reports, which then are referred to the Bureau of Special Investigations, Thompson said. The Bureau’s auditors then refer the reports to the AG’s office for investigation if warranted.

“In a case like this, a report would be sent to the State Auditor either from MassHealth, the administrative service that is providing the care or tips from other services that are helping the individual,” Thompson said.

Loftus said Mass. Gov. Deval Patrick intends to give MassHealth’s program an additional $1.5 million in his budget to help prevent fraud abuse in an automated predictive modeling program. The program does checks to try to identify fraud and further strengthen MassHealth’s integrity program, Loftus said.

Kevin Outterson, professor at the Boston University School of Law, said schemes such as these are common nationwide.

“These particular cases are not unusual in the slightest,” he said. “They happen every day across the nation.”

He said medical programs like MassHealth depend on computer systems too much for healthcare payments.

“Unfortunately, most medical systems operate on a pay-and-chase system — pay the bill and chase them if it is wrong or fraudulent,” Outterson said. “These schemes are common nationwide and Medicare, Medicaid and private insurers rely on computer systems to try to identify the criminals.”

Thompson said the discovery of the individuals who defrauded the MassHealth program shows the healthcare system is working.

“What’s important is that our investigations ensure that a social safety net is in place for those who really need it,” Thompson said. “And that the public is aware that the government is looking to weed out fraud to provide help to those that truly need it.”

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