An administrative crackdown on Ohio Medicaid vendors at high risk for fraud or abuse has shut down several agencies in this area and identified hundreds of rules violations across the state, according to an I-Team analysis of program data.
This success has led Ohio Medicaid to extend its $601,965 annual contract with the Public Consulting Group, which expired last month.
“(PCG has) proven to be an effective resource in conducting on-site visits for provider types deemed to be high-risk,” said Medicaid Spokesman Sam Rossi.
State and federal Medicaid officials have identified certain types of Medicaid programs as high-risk for fraud. They include ambulette services, home health care agencies and durable medical equipment providers.
The cost to Medicaid for these services has grown in recent years. Last year Ohio Medicaid paid more than $22 million for ambulette services in 2014, more than $114 million for medical equipment, and more than $383 million for home health services.
Those costs include only the few percent of Medicaid consumers paid for directly by the state. Nearly 80 percent of Medicaid patients in Ohio are on managed care plans in which the state pays per-person and the plan handles all the billing.
The state paid $62,392 to Hashim Salih, who operated a wheelchair van business in Dayton under the name Nubta Trans. The state terminated Salih’s contract in June 2014 after a surprise site inspection found the company not complying with numerous program rules, including ensuring drivers had necessary licenses and conducting criminal background checks.
Salih voluntarily terminated his Medicaid agreement after the inspection.
An April 2014 I-Team investigation found the company was under-reporting to the Ohio Department of Public Safety how many trips it was providing. That story reported that fraud was a widespread problem in Ohio’s wheelchair van, or ambulette, industry — totaling more than $10 million in improper Medicaid billing and dozens of criminal investigations.
Rossi said PCG visits are conducted usually when a company provides a new application or attempts to renew its contract with Ohio Medicaid.
“Common findings include: failure to check federal exclusion database, failure to have current drivers’ abstracts (records), failure to provide proper record storage,” he said.
PCG inspections found more major program violations at ambulette companies than at all other types of high-risk companies combined. From when inspections started in late 2013 to February of this year, 384 companies were inspected. More than half were wheelchair vans.
After inspections, five of the 384 terminated their contracts with Ohio Medicaid and five withdrew their application to the program.
This includes a home care agency in Springfield called Future Sights, LLC; and Fairfield Home Health Agency in the city of Fairfield. Neither company could be reached for this story.
Major rules violations were found in at least 89 inspections — more than half of them wheelchair van companies.
These inspections have led to criminal investigations, according to the Ohio Attorney General’s Office.
On March 4, 2014, for example, PCG attempted an onsite visit at the Cleveland business address provided by Shaffold’s Transportation Services.
“(PCG) discovered the address to be a strip mall with a SAVE-A-LOT grocery store and a UPS Store,” said AG’s office spokeswoman Jill Del Greco. “The Ohio Department of Medicaid referred this matter to the Medicaid Fraud Control Unit for investigation.”
The investigation found company owners Leon and Antoinette Shaffold believed that they were ineligible to be Medicaid providers due to prior criminal convictions, so they forged the signature of a relative on their application documents.
They then billed Medicaid for services they did not provide, and for people who didn’t need a wheelchair van, in violation of Medicaid rules and their provider agreement, she said.
This month, Leon Shaffold pleaded guilty to theft and was sentenced to six months in jail, suspended, and five years of community control. He also was ordered to pay Medicaid $38,045.77. Antoinette Shaffold pleaded guilty to forgery and is awaiting sentencing.
The I-Team requested actual inspection reports from Ohio Medicaid for PCG inspections where major violations were found or where the provider withdrew, but the request was denied because the state claims the reports contain names of people under criminal investigation.
The newspaper sent a letter to the state through its attorney appealing the decision to deny the records.