Program Fraud Indictments Announced

Stephen R. Wigginton, United States Attorney for the Southern District of Illinois, and Gerald Roy, Special Agent in Charge, United States Department of Health and Human Services, Office of Inspector General, Office of Investigations for Region 7 (Kansas City office), announced today a second wave of indictments arising out of the abuse of a Medicaid program in Illinois that pays personal assistants to assist Medicaid recipients with general household activities and personal care. The program is intended for recipients under 60 years of age and is ostensibly designed to reduce Medicaid expenditures by avoiding more expensive institutional care, including nursing home care.

In this second wave, fifteen individuals, who reside throughout southern Illinois, have been charged in twelve separate indictments by a Federal Grand Jury in Benton, Illinois with the offense of Health Care Program Fraud. The charges carry a maximum penalty of 10 years imprisonment, a $250,000 fine, and up to 3 years of supervised release.

Due to numerous complaints concerning the Home Services Program, law enforcement agencies in southern Illinois initiated a project to investigate and hold accountable individuals perpetrating fraud against the Home Services Program. These indictments allege that the charged individuals exploited the Home Services Program and received Medicaid funds to which they were not entitled. Several investigations uncovered services being billed, but not performed, due to the personal assistant being in jail or out of town. Other investigations revealed the beneficiary residing in a hospital, a nursing home, or out of town at the time the services were supposedly rendered at the beneficiary’s home. It was also learned that some personal assistants and beneficiaries were receiving the Medicaid payments for services not rendered and simply splitting the paychecks. One of the worst examples of fraud on the program, as alleged in the charging documents, was a beneficiary who got out of jail for a one day furlough to meet with his case worker at home so he could continue receiving the Home Services Program benefits. Allegedly, that beneficiary got approved for the services and then returned to jail. It is further alleged that Medicaid paid for personal assistant services not knowing the beneficiary was in jail for several months.

The persons charged in this wave, their ages, and their last known city of residence are:

Sherri R. Goree, age 36, East St. Louis, Illinois
Lisa C. Luckett, age 49, Cahokia, Illinois
Henry J. Billups, III, age 48, Cahokia, Illinois
Karashia A. Tabbs, age 45, Cahokia, Illinois
Valeria W. Johnson, age 56, Centerville, Illinois
Roslyn R. James, age 47, Alton, Illinois
Irma Jones, age 67, Centerville, Illinois
Rosalyn Ross, age 46, Swansea, Illinois
Betty Jean Mays, age 43, Centralia, Illinois
Michael E. Mays, age 53, Centralia, Illinois
Brian D. Adams, age 31, Mount Vernon, Illinois
Tisa V. Vaughn, age 49, Florissant, Missouri
Donald Ray Keip, age 39, Mount Vernon, Illinois
William Dale Sidener, age 30, Ramsey, Illinois
Darron A. Suggs, age 39, East St. Louis, Illinois

An Indictment is a formal charge against a defendant. Under the law, a defendant is presumed to be innocent of a charge until proved guilty beyond a reasonable doubt to the satisfaction of a jury.

This round of indictments brings to twenty-nine (29) the number of defendants who have been indicted for abusing the program. Defendants include both Medicaid beneficiaries (eleven) and personal assistants (eighteen). The first wave of indictments began on May 24, 2012. Most of the indicted cases involved alleged collusion between the beneficiaries and the purported personal assistants.

While the stated purpose of the program is to keep Medicaid recipients in their home and out of more costly institutional settings, prosecutions to date have shown an essential failure to achieve these stated objectives. Cases we have prosecuted include the following:

• Personal assistant boyfriend claimed to be providing personal care to his girlfriend, a Medicaid recipient, while she was in jail. The case came to light when the girlfriend got mad and turned her boyfriend in when her boyfriend would not use the fraud proceeds to bail her out of jail.

• Medicaid recipient who agreed to split the proceeds with a friend for being a no show was later jailed on other charges and continued to receive and split the fraud proceeds with her no show friend. The recipient was caught when she was turned in because she stopped certifying payment for the no show because she selected another friend to receive the no show money.

• Stepmother claimed jailed stepson as her personal assistant for over seven months while he was in jail.

• Medicaid recipient who was jailed for six months was able to get a furlough so that he could meet with his caseworker at his home to continue his purported eligibility. The recipient's friend was his alleged personal assistant and received payments from the State of Illinois for home care while her friend was in jail.

• Personal assistant was claimed to be providing in home personal care services to Illinois Medicaid recipient despite the fact that she was a full time resident of Texas.

• Personal assistant in Illinois claimed to be continuing to render home care services despite the fact that the Medicaid recipient had moved to the State of Texas.

• Medicaid recipient signed up for the program as a means of generating money to pay for an apartment for her daughter once the daughter got out of prison. Her daughter provided no services. Recipient did not need the services as she had been living with her boyfriend and taking care of him for years.

• Blind recipient whose son was paid for providing health care services had to care for herself. When she told her son that the money he was receiving from the State was intended to pay him for care he provided to his mother, his response was that the State wasn't paying him enough to provide her that care.

• Personal assistant continued to receive payments from the State for home health care despite the fact that the recipient was in a hospital and then in a nursing home.

“We have seen dozens of instances in which the State of Illinois paid for ghost employees and fictitious services. Except for one case, payments from the State of Illinois did not keep anyone out of an institutional setting.” said Stephen R. Wigginton, United States Attorney for the Southern District of Illinois.

“In one case in which payments by the State of Illinois kept a Medicaid recipient out of a nursing home, the consequences for the Medicaid recipient were catastrophic. A family friend who herself was on disability became the personal assistant for the Medicaid recipient. This friend even invited the Medicaid recipient into her own home. However, she misappropriated her daughter's name and used a neighbor's name for purposes of obtaining and receiving personal assistant payments from the State of Illinois to care for this Medicaid recipient because she did not want to lose her own benefits. This personal assistant ignored serious and ongoing medical issues suffered by the recipient which should have led to hospitalization, but instead the personal assistant kept the recipient in the home and continued to receive personal assistant payments from the State. That recipient died in the personal assistant’s home as a result of malnutrition and sepsis due to neglect of medical, nutritional and hygienic care.” noted United States Attorney Wigginton.

Nationwide, one of the biggest fraud problems in the Medicaid program has been these personal assistant programs which represent the number one fraud complaint to state Medicaid fraud units. Especially vulnerable to fraud are programs, such as the one implemented in Illinois, that allows the Medicaid recipient to control the selection and payment of personal care attendants. In most cases, the personal care assistant is a relative or family friend, who often is a ghost employee. In a typical fraud scenario, the scam payments made by the State of Illinois are split between the Medicaid recipient and the ghost employee.

According to an Office of Inspector General report released in December, 2012, Medicaid costs for personal care services in 2011 totaled $12.7 billion, a thirty five percent increase since 2005. The U.S. Department of Labor projects that the employment of personal assistants and home health care workers will grow by 46 percent by 2018. U.S Department of Health and Human Services, Office of Inspector General: Personal Care Services, Trends, Vulnerabilities, and Recommendations for Improvement, OIG-12-12-01 (November 2012). Home personal care is one of the fastest growing job categories in the country. However, the OIG’s report points to numerous problems in Medicaid personal care services that leave it vulnerable to improper payments, abuse, and fraud, including lack of training standards, uneven oversight of services provided, and failure to implement prepayment controls to prevent improper or fraudulent payments.

A number of these problems can be seen in Illinois’ Home Services program. Unlike the majority of states, Illinois has no mandatory training requirements for its personal assistants. The State of Illinois sets wages and pays the personal assistants directly, yet does not require them to receive any instruction or education concerning their obligations as caregivers or as paid providers of Medicaid services. Also unlike most other states, Illinois also has no formal mechanism to supervise the work of the personal assistants it pays and ensure that the services it pays for are actually being rendered. U.S. Department of Health and Human Services, Office of Inspector General: States' Requirements for Medicaid-Funded Personal Care Service Attendants, OEI-07-05-000250 (December 2006).

Like only a handful of States, the State of Illinois has a collective bargaining agreement with the personal assistants selected by its Medicaid recipients. The Service Employees International Union is the exclusive representative of the personal assistants. Illinois withholds union dues from the payments it makes to the personal assistants.

Under recent collective bargaining agreements with the Service Employees International Union, the Union has been paid $2 million annually by the State to conduct a voluntary training program for Personal Assistants. While the Union developed and offers training, the investigation has shown that it is attended by almost no one in the Southern District of Illinois and has been of no practical benefit in deterring fraud or insuring that services are performed properly.

While the stated purpose of the program is to keep Medicaid recipients in their home and out of more costly institutional settings, prosecutions to date have shown an essential failure to achieve these stated objectives. Rather than assisting beneficiaries in legitimate need of care, the Medicaid agency in numerous instances is allowing the Home Services program to be exploited by unscrupulous individuals who believe that personal care services are an easy target for fraud.