Sample of Investigations
Investigation with SSA-OIG:
OIG conducted a joint investigation with the Social Security Administration OIG (SSAOIG) in which a recipient was suspected of fraudulent activity in both state and federal programs. Agents discovered that, for several years, the recipient failed to disclose that he owned a maintenance business. When the recipient finally began reporting the business, he underreported the income, stating he made approximately $5,000 a year. Agents found unreported yearly income of over $123,000 in 2016 alone. The recipient was charged and convicted of welfare fraud. He was sentenced to one year in jail, followed by 60 months of probation. In addition, he was ordered to pay restitution of over $135,000.
OIG received a complaint identifying a recipient that had multiple names and social security numbers assigned to her. The OIG investigation confirmed that she received concurrent FAP benefits under two different names. She also failed to report employment and Retirement Survivors and Disability Insurance benefits. The investigation identified $8,895 of FAP benefits she received that she was not eligible for. The OIG agent submitted a warrant request to the prosecutor’s office requesting welfare fraud charges.
MDHHS Employee Fraud:
An OIG investigation determined that a MDHHS employee entered false information into a state database to obtain fraudulent Adult Home Help payments. The employee was charged with fraudulent access to computers, computer systems and computer networks and false pretenses. The employee was convicted of false pretenses, ordered to pay over $77,000 in restitution to MDHHS and serve 60 months of probation.
FAP Trafficking Scheme:
An OIG agent uncovered a conspiracy where an individual utilized FAP benefits to supply retail stores with stock. The individual, acting as an intermediary, purchased FAP benefits from recipients at a reduced rate and used the benefits to purchase products which were then sold to convenience stores for retail sales. Over $100,000 in FAP benefits were misused in the scheme, which resulted in criminal charges and enforcement actions involving multiple suspects.
OIG utilized a data match to identify a Medicaid and FAP recipient that failed to report to MDHHS that her husband, also her children’s father, resided in their home. In the course of the investigation, it was determined that the husband was using a stolen Social Security number to hide his income from the department. His income would have made their household ineligible for both programs. OIG gathered evidence to prove he was in the home and the unreported income. The recipient was charged and convicted of welfare fraud and sentenced to 60 months of probation and restitution of over $40,000.
Identity Theft Investigation:
An OIG agent uncovered a scheme involving the use of multiple fraudulent identities to illegally obtain FAP benefits. The investigation identified a business owner and his wife who used nearly $15,000 in fraudulent benefits to purchase stock for his restaurant. The couple also concealed the profits from their business and received personal public assistance program benefits to which they were not entitled. Both were charged with multiple felony counts of conducting a criminal enterprise and food stamp fraud.
Child Day Care Provider Overbilling:
OIG received a fraud referral that identified billing irregularities regarding a provider in the Child and Development Care program (CDC). Attendance records maintained by the provider did not match the provider’s billing/attendance invoices submitted to MDHHS for payment. Evidence was gathered verifying the dates and times the parents utilized child daycare. OIG’s investigation determined that the provider had overbilled the State of Michigan for childcare services. The provider was charged and convicted of false pretenses and welfare fraud. The provider was ordered to pay $53,509 in restitution, serve 60 months of probation and 150 hours of community service.
Unreported Business Ownership:
OIG received information that a recipient underreported his earned and unearned income, which if it had been reported, the recipient would have been ineligible for Medicaid. During the investigation, OIG discovered that the recipient had applied for a commercial bank loan. OIG obtained records which confirmed the client owned and operated a hotel in Wisconsin, where he also resided. Bank records revealed the recipient had gross earnings that far exceeded the income limits for Medicaid. The recipient’s failure to report accurate income and residency to MDHHS resulted in $15,181 of Medicaid benefits which he was not eligible for. The recipient was charged with welfare fraud, failure to inform and false pretenses.
Pharmaceutical inventory audits are performed to validate that items supplied to Medicaid beneficiaries are supported by purchase invoices, as required by Medicaid policy.
In FY 2018, 22 pharmacy providers agreed to repay the Medicaid program a total of $3.9 million as a result of pharmaceutical inventory audits.
An additional 28 pharmacy provider cases are pending appeal decisions, litigation or repayment terms negotiation. These cases represent approximately $14.7 million.
In FY 2018, receivables were established for 506 home help providers totaling $989,540 for payments made while their beneficiaries were hospitalized, after their death, while the provider was incarcerated or for other noncompliance with Medicaid policy.
An additional 20 home help provider cases are pending appeal decisions, litigation or repayment terms negotiation. These cases represent approximately $2.3 million.
In FY 2018, 32 providers agreed to repay the Medicaid program a total of $553,903 that they received as a result of double billing for injectables.
In FY 2018, 11 laboratory providers agreed to repay the Medicaid program a total of $255,592 that they received as a result of billing for services that violated Medicaid Policy regarding referring providers of genetic testing.
Durable Medical Equipment (DME):
In FY 2018, 17 DME providers agreed to repay the Medicaid program a total of $182,917 that they received as a result of billing for oxygen and oxygen supplies for patients who did not meet the Medicaid requirements for oxygen saturation.
In FY 2018, 11 pharmacy providers agreed to repay the Medicaid program a total of $141,550 as a result of billing for pharmaceuticals using the wrong unit of measurement (i.e., mg instead of ml).
In FY 2018, 18 ambulance providers agreed to repay the Medicaid program a total of $113,833 that they received as a result of billing for advanced life support, when basic life support was more appropriate.
In FY 2018, 10 dental providers agreed to repay the Medicaid program a total of $76,938 that they received as a result of billing for services that violated Medicaid Dental Policy.
Maternal Infant Health Program (MIHP):
In FY 2018, 21 MIHP providers agreed to repay the Medicaid program a total of $69,194 that they received as a result of billing for services that violated Medicaid MIHP Policy.
Private Duty Nursing (PDN):
In FY 2018, ten PDN providers agreed to repay the Medicaid program a total of $62,987 that they received as a result of billing for services that violated Medicaid Policy, including billing for services while the beneficiaries were hospitalized.