The CEO of a behavioral health care company has agreed to plead guilty to six counts of healthcare fraud.
Miguel Saravia, CEO of Dana Group Associates and former chief operating officer of Prime Behavioral Health was charged earlier this month to taking part in a scheme to defraud insurers.
The Healthcare Fraud Scam
According to the government, between 2017 and 2022, Saravia directed employees with no billing experience or medical training to enter medical codes for therapy services that were not provided. He also directed them to upcode for psychotherapy visits. Upcoding is healthcare fraud and, occurs when a healthcare provider submits diagnostic and treatment codes to Medicare, Medicaid, or private insurers for more serious — and more expensive — diagnoses or procedures than the provider diagnosed or performed.
Saravia faces up to up to 10 years in prison, up to three years of supervised release, and a fine of up to $250,000, or twice the gross gain or loss from the offense.
Mental Health Industry Ripe for Healthcare Fraud
With the nation in the throes of a mental healthcare crisis, behavioral healthcare services are increasingly vulnerable to fraud, waste and abuse by bad actors. The industry has seen a significant uptick in behavioral healthcare fraud, particularly after the pandemic when treating patients via telemedicine increased significantly.
There are various ways those bad actors are gaming the system. One of the most common schemes is upcoding 45-minute psychotherapy sessions to 60-minute sessions to increase reimbursement.
Another way is to add evaluation and management (E/M) services. For example, a provider adds an E/M code for a medical service during office visit to a procedure code for an hour-long psychotherapy session but doesn’t provide proper documentation to distinguish between the two services.
Other Behavioral Healthcare Fraud Cases
Earlier this month, a Sioux City, Iowa mental health counselor was charged with providing false medical codes on patient’s bills to provide additional reimbursement to which she was not entitled.
According to court documents, Amy Hecht used a billing code that was to be used for when “when additional needs or work or complications occur during treatment for a patient.” Employees allegedly noticed the code being added to their treatment notes and the billing when they never added the coding.
In Fayetville, N.C. a clinical mental health counselor supervisor pleaded guilty in August to 21 counts of obtaining property by false pretenses. Valerie Ann Sinclair submitted fraudulent claims for behavioral health services to 21 Medicaid recipients, including many children, that she had not provided.
And in Phoenix, Arizona, the owner of two behavioral health counseling services was sentenced last month to 66 months in prison after pleading guilty to wire fraud and money laundering. It was alleged that Diana Marie Moore engaged in a fraudulent billing practice that targeted Native Americas seeking behavioral health services. It was alleged she bilked the government out of more than $21.7 million in this healthcare fraud case.
How We Can Help
As with any type of healthcare fraud, having a compliance program in place not only can catch healthcare fraud at the inception, but it also can be seen as a mitigating factor if your practice becomes the target of a healthcare fraud investigation.
The Health Law Offices of Anthony C. Vitale can assist in setting up a comprehensive compliance program. Our seasoned healthcare attorneys also can provide trusted, reputable leval advice and defense. Should you become the target of a healthcare fraud investigation, our lawyers will aggressively protect your best interests and advise you of all options and best steps to take moving forward.
For more information, contact us at 305-358-4500 or send us an email to info@vitalehealthlaw.com and let’s discuss how we might be able to assist you.
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