Medicare Fraud Involving False LSCW Qualifications

There are millions of Americans receiving counseling services and mental health care. Many of the patients receiving these services are on Medicare or Medicaid. Doctors’ offices and clinics that provide these services have an obligation to ensure those that provide these important services are properly trained and qualified.

Medicare Fraud Involving False LSCW Qualifications

In this post we discuss a recent case where the government claimed a Delaware provider accused of billing for unqualified Licensed Clinical Social Workers. Earlier this month the Justice Department intervened in a case alleging that Connections Community Support Programs, Inc. billed for unqualified providers.

Much of the healthcare we receive in the U.S. is paid by tax dollars. If you are a Medicaid, Medicare or Tricare recipient, your care is subsidized with tax dollars. Uncle Sam says that in order to be paid, providers must both be qualified and certified. Let’s discuss what those words mean.

Connections Community Support Programs is a Delaware based mental health services company. According to their website they provide array of mental health and other services to residents of Delaware and parts of Maryland. They also claim to be one of Delaware’s largest non-profits with 100 locations and 1,200 employees.

Prosecutors say the company claimed that patients were seen by a licensed clinical social worker and other similarly qualified professionals. The people actually providing the services  weren’t qualified. The government’s complaint says  patients were often seen by unsupervised and unqualified workers.

According to a complaint filed Friday,

“From at least January 1, 2015, through at least October 31, 2019, Connections, one of the largest providers of outpatient mental health and substance abuse services in Delaware, fraudulently billed Medicare and Medicaid by at least (i) billing for mental health services rendered by individuals whose professional qualifications did not allow them to bill Medicare or Medicaid for reimbursement under the names of individuals whose qualifications did allow for reimbursement and (ii) billing Medicaid for mental health services using incorrect procedure codes for the person performing the service, resulting in higher payments to Connections than were permitted.

“In falsely certifying the identity of the individual providing the mental health service, Connections, in violation of the False Claims Act, caused Medicare and Medicaid to pay for millions of dollars in services for which Connections was not entitled to reimbursement.”

The original complaint was filed in 2019 by two former employees of the company who recognized the fraud and became whistleblowers.

False Claims Act and Whistleblower Rewards

The case against Connections Community Support Programs was filed as a whistleblower complaint under the False Claims Act. Passed during the American Civil War, that law allows whistleblowers with inside information about fraud involving government programs to receive a cash reward. Typical rewards are between 15% and 30% of whatever the government collects from the wrongdoer.

Collecting a whistleblower reward involves filing a sealed lawsuit in federal court. While that sounds like a daunting task, there are several law firms that represent whistleblowers and do most of the work.

These lawsuits are sealed meaning they are secret. This allows the government to interview witnesses and quietly gather evidence. Because the complaints are secret, employees are better protected from retaliation and harassment. (The False Claims Act has strong protections against retaliation. These include double lost wages and legal fees.)

Often these investigations can take a year or more. Even though retaliation is illegal, some healthcare workers use the time to find another position. Once the investigation is complete, the case is unsealed. At that time the government can “intervene” and take over the case or allow the whistleblower’s own lawyers to prosecute. If the investigation clears the defendant of any wrongdoing, the case is typically dismissed.

In the case against Connections Community Support Programs, Justice Department prosecutors elected to intervene and take over the whistleblower’s case. According to the government’s complaint, at least 4,000 claims were submitted by Connections falsely claiming that the services were provided by licensed social workers.

A Justice Department spokesperson on said,

“Federal healthcare regulations and policies that govern mental health services exist to ensure that Medicare and Medicaid beneficiaries are treated by qualified professionals.  We expect all providers to submit claims that are true, accurate, and complete, and entrust that they will do so.  Connections violated that trust, and in the process, defrauded Medicare and Medicaid out of more than $4.5 million dollars.  My office is committed to pursuing all providers who submit false claims to federal healthcare programs to obtain money to which they are not entitled.”

In a separate action, prosecutors also accused Connections and three of its officers with violating the Controlled Substances Act. They say the company can’t account for hundreds of doses of methadone and other narcotics.

Whistleblower cases under the False Claims Act allow the government to collect triple damages and high fines of over $20,000 per each improper service billed to the government. That means fines and therefore whistleblower rewards can quickly reach into the millions of dollars.

[We remind readers that the government’s decision to intervene in a Medicare fraud case is not a finding of wrongdoing. Connections, like all defendants, is entitled to their day in court.]

False Credentials or Unqualified Professionals

Earlier we said there is a difference between unqualified healthcare workers and those without proper credentials. A practice that uses unqualified workers means the people caring for patients lack the proper qualifications or training. The use of unqualified workers is actually quite dangerous.

Uncredentialed healthcare workers or those lacking proper credentials may or may not be qualified but until they get their certifications and get approved by Medicare, they can’t bill for their services. Sometimes we see people who can’t get certified because of something g in their background or prior abuse reports.

Either way, it is a violation for a doctor’s office or clinic to bill for unqualified or uncredentialed workers. Ask most patients and they would agree. When they see a clinician, they have the right to believe that the person caring for them or a loved one is fully trained and certified.

Do You Have Information About Unqualified or Uncredentialed Healthcare Workers?

If you have inside information about healthcare workers who are not credentialed or not qualified, you may be entitled to a cash reward. The False Claims Act pays rewards nationwide for information regarding healthcare billed to Medicare, Tricare or Medicaid. 29 states and the District of Columbia pay for rewards regarding state funded Medicaid. (Even if your state isn’t on the list, the federal government will stay pay a reward based on the federal match portion of Medicaid.)

To obtain a reward, you need an attorney to help you file a sealed case in court. Sealed means secret. Your case will remain confidential while investigated by authorities. Ultimately the government or your lawyer will be able to prosecute the case once the investigation is complete. In some instance authorities may ask the court to dismiss the case.

See Something? Say Something.

If you are a healthcare worker with inside information about fraud involving a government funded healthcare program, you may be entitled to a large cash reward. We will help you obtain a reward and stop the fraud. Calling our hotline will put you in contact with a whistleblower lawyer who can help you assess your case and file for a reward.  

Medicaid Fraud Hotline: 888.742.7248 or REPORT ONLINE AND CLAIM A REWARD

Are you a patient? A healthcare professional not interested in a reward or wanting to remain completely anonymous? Contact Medicare directly at 1-800-MEDICARE or the state Medicaid Fraud Control Unit in your state. (There are no rewards for reporting directly to Medicare or the state. You must file a lawsuit in order to qualify for a reward.)

[Photo under license from Upspash]


Medicaid Fraud Hotline: 888.742.7248 or Report Online
and claim reward