Maryland’s Attorney General’s office announced that Jemina Saka, a 32-year-old from Street, Maryland (Harford County), has been indicted on charges of felony Medicaid fraud and felony theft.
Saka, who is not a licensed or certified healthcare provider, was employed by a home health agency to provide assistance to a vulnerable adult for up to 35 hours per week. This is the last person that should be a victim, right? An investigation conducted by the Attorney General’s Medicaid Fraud Control Unit revealed that from June 2021 to June 2022, Saka submitted time sheets indicating that she was providing 35 hours of home health care to the individual, despite not being in the State of Maryland at the time.
During her shifts, Saka was found to be out of state or at a location in Maryland that was not near the individual’s home, resulting in a loss of at least $4,300 to the Medicaid program. Saka was arrested in Florida and is awaiting extradition to Maryland to face prosecution in Baltimore County.
$21 Million Medicare Fraud Settlement
The $4,200 at issue in the Hartford County case is chump change. But $21 million is not. The U.S. Department of Justice’s Southern District of Texas announced that a Houston-based Cornerstone Hospital Medical Center has agreed to pay over $21 million to resolve a federal lawsuit that accused the company of defrauding Medicare for years.
Cornerstone Hospital Medical Center was a hospital that provided extended medical and rehabilitative care to clinically complex individuals with multiple acute and/or chronic conditions. The fraud investigation began in 2018, after a whistleblower’s tip, and it uncovered that from January 1, 2012, through December 31, 2018, Cornerstone Medical Center had billed Medicare for services not supported by the patient’s diagnosis or medical records. Additionally, the hospital billed for services that were either not rendered or were so inadequate that they were worthless, and in some cases, harmful to the patients.
This fraudulent activity was found to have violated federal law, and as a result, the company has agreed to pay $21.6 million to settle the lawsuit. FBI Houston officials have stated that this is one of the largest civil healthcare fraud settlements they have seen, and it should serve as a warning to other healthcare providers who may be considering similar fraudulent activities.
What Is Medicare Fraud?
Medicare fraud is a type of healthcare fraud that involves making false or misleading statements or representations to obtain Medicare program benefits or payments. It can occur in a variety of ways, such as billing for services that were not provided, performing unnecessary procedures, or misrepresenting the diagnoses or conditions of patients. Medicare fraud can involve healthcare providers, patients, or even individuals who work for or operate Medicare-contracted organizations.
Medicare fraud is a serious offense that can result in significant financial losses to the government and taxpayers. It can also lead to increased healthcare costs and reduced quality of care for patients. Medicare fraud is a federal crime and can result in civil or criminal penalties, including fines, imprisonment, and exclusion from the Medicare program. The government has established the Medicare Fraud Strike Force to investigate and prosecute Medicare fraud, and encourages individuals to report any suspected cases of Medicare fraud.
The Medicare Fraud Strike Force is a joint effort by the Department of Justice (DOJ) and the Department of Health and Human Services (HHS) to prevent and combat healthcare fraud and related offenses. The Strike Force focuses on investigating and prosecuting fraudulent activities related to Medicare and other government healthcare programs.
The Medicare Fraud Strike Force operates in nine regions across the country, with teams of federal prosecutors, agents from the Federal Bureau of Investigation (FBI), and other law enforcement agencies. The Strike Force’s primary objective is to identify and prosecute healthcare providers and other individuals who engage in Medicare fraud and related offenses.
The Strike Force employs a data-driven approach to identify and investigate suspicious billing patterns, claims, and providers. It also coordinates with other agencies, such as the Centers for Medicare and Medicaid Services (CMS), to share information and detect potential fraud schemes.
How You Can Profit from Medicare Fraud
Honest citizens can profit from Medicare fraud, as crazy as that sounds. The Medicare Whistleblower Program provides a financial incentive for individuals who report fraudulent activity against Medicare. If a person has evidence of Medicare fraud, they can report it to the government and potentially receive a whistleblower reward.
The False Claims Act offers a whistleblower reward ranging from 15 to 25 percent of the amount the government recovers based on your report of Medicare fraud or Medicaid fraud. To receive the reward, you can hire an attorney – we do this work for very large Medicare fraud claims – who will work on a contingency basis to file a lawsuit against the hospital or healthcare provider committing the fraud.
The key is convincing the government to take a Medicare fraud case. From there, the government does all of the work. So your lawyer needs to spoon feed specific and detailed evidence that the healthcare provider was indeed committing fraud against Medicare or Medicaid.
So the way it works is to receive a reward, the whistleblower must file a lawsuit on behalf of the government, which is known as a qui tam lawsuit. The lawsuit must be filed under seal and must include specific details of the fraudulent activity. The government will then investigate the claim, and if it finds that the allegations are valid, it may choose to join the lawsuit. If the government jumps in, your chance of success skyrockets.
For instance, if a hospital wants to defraud Medicare and Medicaid by upcoding or billing for unnecessary services, the whistleblower reward would only consider the fraud against Medicare or Medicaid or other government programs, not private insurance companies. Reporting an isolated instance of fraud is unlikely to result in a reward. The key to receiving a reward for reporting Medicare fraud is to have evidence of widespread fraud against Medicare or Medicaid.
Getting a Lawyer for a Whistleblower Claim
If you suspect Medicare fraud and have evidence to support your claim, speak with an experienced attorney who can guide you through the process of filing a qui tam lawsuit and help you maximize your chances of receiving a whistleblower reward. If you case is like the Hartford County case above with $4,200 at issue, it is hard to get a lawyer excited about bringing that type of case for you. The polar opposite of that is the $21 million fraud case in Houston. There are a ton of lawyers who will help you bring a claim of large and systematic fraud.
- Speaking of Medicare, Maryland lawyers need to make sure Medicare liens are satisified or the government will not be happy
- New Maryland appellate opinion on a judge’s discretion on sentencing