FBI says APS Healthcare failed to provide contracted services to Georgia's Medicaid population
The United States Attorney’s Office and the Federal Bureau of Investigation (FBI) have announced that “INNOVATIVE RESOURCES GROUP, LLC,” doing business as “APS HEALTHCARE MIDWEST,” of White Plains, New York, has reached a $13 million settlement with the United States and the state of Georgia to resolve allegations under the False Claims Act.
The FBI noted that the federal government's share of the settlement is $5.2 million. The government alleges that APS Healthcare submitted false claims to Medicaid through the Georgia Department of Community Health (DCH) because it did not provide specialty services related to disease management and case management to members of the Georgia Medicaid Management Program (GAMMP) during the period from September 1, 2007 through February 28, 2010.
United States Attorney Sally Quillian Yates said of the settlement, “In this time of tight budgets and rising health care costs, the state of Georgia tried to improve its services to its Medicaid recipients by contracting with APS Healthcare. But instead of providing improved efficiency and effectiveness the company billed for, APS Healthcare took Medicaid’s money for itself and left some of our most vulnerable citizens without the aid they deserved.”
“Investigating Medicaid grant fraud is an important priority, because it diverts desperately needed resources from those who need it most,” said Special Agent in Charge Derrick L. Jackson, Health & Human Services, Office of Inspector General, Atlanta Region.
“This substantial recovery of taxpayer dollars is attributable to the continued strong partnership between state and federal law enforcement agencies in the fight against health care fraud and abuse,” said Scott Smeal, Georgia Senior Assistant Attorney General. “This case should send a strong message to companies such as APS Healthcare that they will be held fully accountable when they fail to provide the services they promised to provide to Medicaid patients.”
The FBI says, APS Healthcare agreed to provide case and disease management services to Georgia Medicaid recipients and was paid a monthly fee for each member receiving such services. The government contends that APS Healthcare failed to provide the required services to a large portion of the Medicaid recipients and over-billed the Georgia Department of Community Health in its monthly invoices.
APS Healthcare has executed a Corporate Integrity Agreement (CIA) with the federal Department of Health and Human Services, Office of Inspector General, which will require an aggressive compliance program. The Corporate Integrity Agreement requires, among other things, intensive training and implementation of policies and procedures designed to ensure compliance with federal health care program requirements.
APS Healthcare's Response
In a press release on its website, APS Healthcare offers an interesting, if not, weak defense saying: "This disagreement centered around a lack of clarity in certain provisions of the original contract and it is for that reason we strongly deny the allegations made against IRG,” said Greg Scott, chief executive officer for APS Healthcare. “We had notified the Georgia Medicaid program of these ambiguities long before the case was filed, and had proactively worked to clarify and address them."Scott continues, adding: "At all times we operated within the terms of the contract. Despite these challenges, we are proud that we accomplished many of the goals of the program and provided valuable disease management services to the State of Georgia’s most needy citizens. In doing so, we significantly improved the health status of many participants in the program. “Rather than engage in a lengthy legal process, we elected to put this disagreement behind us so that we can continue to focus on our core mission to improve the health of the people we serve."
Analysis
In a nutshell its easy to conclude that APS healthcare, at best, lacked appropriate compliance mechanisms to ensure they fulfilled this contract under the agreed upon terms. Since they settled and paid $13 million its easier to conclude though that APS Healthcare got caught shortchanging a huge client... and worse, put the lives of disabled and vulnerable individuals at risk that they were legally obligated to serve, protect, and improve health outcomes against serious and deadly diseases.
Insurance fraud is often depicted as overcharging or scamming clients of hard-earned premium dollars. While that is often the case and is undeniable unethical and cruel, fraud that leaves the ill, poor, and disabled lacking appropriate treatment, care, and disease management goes beyond the "unethical" label, and frankly leaves me at a loss to appropriately describe the harm of such practices to our industry.
