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Nurse owes state $82K for overbilling, officials say

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By Josh Sweigart, Staff Writer Updated 11:40 PM Thursday, February 2, 2012

A Miami County home-care nurse improperly charged Medicaid nearly $70,000 over three years, the Auditor of State announced Thursday.

James Delver, a licensed practical nurse who independently contracts with the state to provide care in a home in Miami County, is accused of charging Medicaid for unauthorized hours despite warnings from his Medicaid case manager, according to state officials.

“When you are told not to do something, and you do it anyway, you are abusing a privilege,” Auditor Dave Yost said. “Providers are responsible for knowing which patients are subject to Medicaid rules for doctor approval and proper standards of care.”

Delver told the Dayton Daily News on Thursday that he will fight the accusations.

He said the “clerical error” was made by CareStar, which manages home-care providers statewide on behalf of the Ohio Department of Job and Family Services.

“Every single hour I was scheduled, I was there. I worked,” Delver said. “I was never asked to not bill for these hours.”

State officials say the problem is that Delver was not authorized to work the hours he billed and was paid for.

The audit says CareStar workers cautioned Delver in 2008 against over-billing.

The audit found nearly $68,529 in payments to be improper.

With interest, the amount owed to the state is $82,422.

Delver was paid a total of $223,133 during the audit period from July 1, 2006, through June 30, 2009.

Auditors identified 67 instances of billing for more hours than allowed under a care plan. In another 197 instances, plans were missing altogether.

Other deficiencies noted in the audit include missing or insufficient plans of care prescribed by a doctor.

The case now goes to the Ohio Department of Job and Family Services to determine whether to collect the money; that agency will work with the Attorney General’s Office to determine if there is any indication of fraud.

Delver said the system is prone to miscommunication. He said he reports a month in arrear how many hours he’s working, sometimes while the approval for how many hours he’s allowed to work is still being finalized. “The system is messed up,” Delver said.

ODJFS has announced it will re-bid its roughly $30 million annual contract with CareStar — overseeing more than 10,000 providers for more than 13,000 clients — after 14-year-old Makayla Norman’s death. The disabled girl starved to death in her Dayton home last year while in home care. The girl’s mother and nurses also facing criminal charges.

CareStar President Tom Gruber said Thursday his company “welcomes a rebid.”

“We have consistently gotten very good reviews from the state,” he said.

A fraud investigation is under way in Makayla’s case. The Daily News has reported that Medicaid fraud is a massive and growing problem in Ohio, fed largely by the growth of in-home care.

Delver is one of 10,489 independent home-care providers in the state, according to ODJFS. In 2010 and 2011, the agency conducted 1,339 investigations — including fraud, abuse, neglect, billing errors and other charges — involving 796 providers. Of these, 577 were substantiated.

State audits of a provider are more rare: 14 since 2010, according to the state auditor’s website.

Contact this reporter at (937) 328-0374.

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