Fraud, overbilling found at AMDCs; Comptroller wants $10.2M returned

TRENTON – Five adult medical day care centers wastefully spent millions of dollars in taxpayer funds, billing the state-funded Medicaid program for services they could not provide documentation for, patients who never attended the facilities, and for individuals who were not eligible to receive care, state Comptroller Matthew Boxer said Wednesday.

As a result of the investigation, the office will seek to recover more than $10.2 million in Medicaid payments from four of the facilities that used the reimbursements inappropriately. They include Home Sweet Home Adult Medical Day Care ($639,812), Belleville Medical Day Care ($4,293,303), Golden Era Adult Medical Day Care ($3,506,692) and Atlantic Adult Day Health Care ($1,786,895). The office said it has already recovered $175,168 from Oceanview Adult Medical Day Care, the fifth facility it investigated.That facility has since sold its license to a group in Mercer County, the office said.

Boxer said those particular centers were investigated by his office’s Fraud Division after receiving several tips and complaints of activity going on there.

“Adult medical day care programs provide an important and necessary service allowing individuals with specialized medical needs to remain active in the community rather than enter more intensive and sensitive in-patient facilities. It is apparent however that greater monitoring of AMDC facilies is needed. The state’s Medicaid program pays these facilities to provide medical and clinical services. When in reality those services are not being provided, this office will move aggressively to recover any taxpayer funds that have been inappropriately spent,” Boxer said.

Some centers couldn’t provide proper documentation for claims related to individuals/patients who were believed to have received services. In other cases, the centers submitted billing for individuals who didn’t attend any of the AMDCs, Boxer’s office reported. One center billed the state for more than a month for a resident who was not receiving care, but was actually on vacation, the comptroller’s office said. In one instance, the state paid more than $10,000 for someone who never attended the facilities, Boxer said.

The level of care provided by the facilities was also questionable, the Comptroller reported. Records reviewed by the office found that one facility failed to perform required monitoring of the patients’ blood sugar and blood pressure, and others had conflicting clinical chart data.

Golden Era Medical Center had a particularly long list of problems the comptroller’s office identified. In addition to the billing for the patient that was actually on vacation on the dates stated, the center provided larger doses of medication to residents, and for a longer period of time, than it was supposed to. Other instances include reporting of false information, such as a resident’s limb being amputated or wearing dentures when they actually weren’t, insufficient blood pressure monitoring, and not providing patients with the number of physical therapy sessions they were supposed to receive, the report said.

Lack of sufficient screenings and monitoring for patients with high glucose and blood pressure were common at Belleville, the comptroller said.

“Records indicate that on one occasion when the recipient’s blood sugar reached a dangerously high level, Belleville attempted to contact the recipient’s physician, but when the facility did not receive a response Belleville never followed up with the doctor,” the report said.  

There were also cases in Belleville where it billed state Medicaid for services for individuals that weren’t even there, according to the office. In another instance, residents were receiving medication they shouldn’t have.

Sloppy documentation was also the norm. For example, a patient had discussed committing suicide with her nurse, but it was never documented in her care plan. Another patient suffering from major depressive disorder was not properly addressed, according to the comptroller’s office.

At HSH, there was an instance where a patient did not receive prescribed eye drops after the patient had undergone cataract surgery.

At Atlantic, the center failed to keep track of its transportation logs or the individuals who entered the facility. The office said Atlantic did not record individuals’ signatures on 133 of the 228 dates, and there was no record at all of the individuals’ arrival/departure times.

To prevent future fraudulent activity, Boxer recommended stronger oversight measures through unannounced site visits and random and routine audits.

While the state is primarily seeking to recoup taxpayer funds that were wastefully spent, it may also seek criminal prosecution, as it works with the state Attorney General’s Office.

The state provides $200 million each year to the state’s 134 AMDCs serving 14,000 residents.

Fraud, overbilling found at AMDCs; Comptroller wants $10.2M returned