Attorney General investigating provider fraud in Medicaid waiver

by Anna Wolfe, Mississippi Today
April 6, 2023

The Mississippi Attorney General's Office is investigating whether a behavioral therapist provider bilked Medicaid under a special program for people with intellectual and developmental disabilities.

Natalie Gunnells, the mother of a 23-year-old Medicaid recipient named Patrick, first noticed a billing discrepancy in early 2022 after requesting to see records from the Mississippi Department of Mental Health.

The Department of Mental Health administers the program, called the Medicaid IDD waiver, but the Mississippi Division of Medicaid pays for it.

Under the waiver, Patrick is eligible to receive over 200 hours of services each month, but in the last several years, he's received just a handful of hours, if not zero.

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That hasn't stopped Mississippi Behavioral Services, a clinic in Southaven owned by Vargas Clark, from billing Medicaid for thousands of dollars worth of therapy for Patrick, records obtained by Mississippi Today show.

Clark, who has not been charged with a crime, said he was unaware of the investigation and did not return several follow up calls and texts from Mississippi Today. Gunnells estimates Medicaid reimbursed the company for $42,000 worth of services that her son didn't receive from 2020 to 2022. She says disregard at the mental health and Medicaid agencies allowed this to continue unnoticed.

“We provide services as written for the service authorization,” Clark said. “Now there may be individuals that are authorized for, let's say, 30 hours. We may be providing 10. But we only bill services for services that are actually rendered.”

Mississippi spends about $125 million annually on the waiver program, an average reimbursement of about $45,000 worth of services for each person.

Several parents who spoke to Mississippi Today and voiced their concerns at a recent public hearing want to know where all that money is going. It's hard for them to believe that much care is being delivered, considering the worker shortage that has left them without any help for their adult children.

And they're worried that a lack of oversight in the program could mean taxpayer dollars are flying out the door of Medicaid while some of the state's most vulnerable residents go without services.

“There's no telling how much fraud is occurring,” Gunnells said.

One of those parents is Deb Giles, who has been unable to find a specialist to provide the speech therapy her son is qualified to receive. But at the hearing in February, Giles focused her concerns on the accountability within the program.

“My recommendation for the Department of Mental Health is to provide the recipients with reports on audits of the providers and to provide more audits,” Giles said. “I've run into roadblocks, and not enough information as to how these providers are being audited. Some are not providing the services that they're being paid for, or reimbursed for, and I would like to see more information for Mississippi on how these providers are being audited. And also I'd like to be able to assess the audits, to read throughout the state of Mississippi what the providers are providing for the recipients.”

Giles told Mississippi Today she wasn't alleging a specific instance of fraud, but that the waiver program doesn't collect enough information from providers to ensure they're performing all the functions they're supposed to.

The Department of Mental Health's primary role in the IDD waiver is to provide clients with support coordinators from the agency's regional IDD centers. The support coordinator's job is to consult with the parent or guardian of an individual on the waiver to ensure they are receiving the services outlined in the support plan they create together. For years, Gunnells said her support coordinator did not review service reports with her. Several call logs Mississippi Today reviewed confirmed that this wasn't happening.

“It seems every standard put in place to ensure appropriate care for P (Patrick) was totally ignored from the Support Coordinator to all his superiors charged with ensuring the documents such as Quarterly Reports, Behavior Support Plan and required IDD service notes were submitted on time and accurate,” Gunnells wrote in a timeline of the alleged fraud. “They were so negligent that any agency billing Medicaid, that wanted to commit fraud, could without detection.”

Department of Mental Health Director Wendy Bailey said the agency conducted its own internal investigation into the matter and referred it to Medicaid. She said DMH is providing additional training to support coordinators and looking at ways to improve its site visit process at the regional centers. The central office reviews a sample of support coordination records monthly.

The state Medicaid agency is in the process of renewing its application to the federal government for the waiver.

“While we don't have evidence to believe this type of provider fraud is widespread, we still have to be open to new ways of preventing fraud and be aggressive in rooting it out,” Medicaid spokesperson Matt Westerfield said in a statement to Mississippi Today. “This year, the Division plans to implement an electronic system for the ID/DD waiver that documents the time certain ID/DD services begin and end.”

The Medicaid statement also encouraged anybody who suspects Medicaid fraud to notify the agency here.

The Attorney General's Office, which began its investigation more than six months ago, did not respond to several requests for comment for this story.

This article first appeared on Mississippi Today and is republished here under a Creative Commons license.

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