Medical Records Reveal Elaborate Billing Fraud in Home Health Care, Resulting in $10M Settlement

Phony Records Were Used to Legitimize Overcharges and Other Fraudulent Billing to MassHealth for Years, Authorities Say

Maestro-Connections Health Systems (Maestro) and its CEO, George Kiongera, have agreed to pay $10 million to settle allegations of fraudulently billing the Massachusetts Medicaid Program, MassHealth, for more than 5 years. This settlement, announced by Attorney General Maura Healey in December 2020, marks a major win in authorities’ efforts to fight Medicare billing fraud in the home health care industry.

Those efforts have put more than $45 million back into the MassHealth program during the 2020 fiscal year alone. They have also revealed how many sophisticated, long-running Medicare billing fraud schemes work—and how medical records play a crucial role in not only committing, discovering, and proving Medicare fraud but also in recovering millions of taxpayer dollars every year.

Audit Discovers Overbilling, Sparks Case Against Maestro

Maestro, established in 2010, bills itself an “affordable home health care services company”. Headquartered in Lawrence, MA, Maestro operates out of Lawrence, Auburn, Lynn, Framingham, Taunton, and Holyoke.

Massachusetts authorities began to suspect Maestro of Medicare billing fraud during a 2016 audit that flagged nine home health care providers as potentially overcharging the state for services. The audit had been triggered by an 82% increase in the program’s home health care spending in merely two years.

As auditors investigated medical bills and records from those nine providers, they reportedly discovered that Maestro’s Auburn facility had overcharged MassHealth by at least $2.5 million. These charges were racked up within a three-month period in 2015, according to auditors. In total, the nine home health care agencies had overbilled MassHealth by about $23 million in just three months.

The auditor, in their medical record review, found that the home health care providers had failed to include dates and signatures on documents submitted to MassHealth and that, in some cases, basic information, like a patient’s medical history, was missing altogether.

Maestro and the others were fined between $3,000 and $10,000 for each overbilling to the state. They were also ordered to submit corrective action plans to MassHealth. Although it’s unclear whether Maestro submitted this plan, what is clear from subsequent investigations is that this agency continued to improperly bill the state for years after the 2016 audit and fines.

A Closer Look at Maestro’s Fraudulent Billing Practices

The $10 million settlement that Maestro will now pay is to resolve allegations that the agency had been fraudulently billing MassHealth from January 2014 through August 2019. In fact, as part of the terms of this settlement, Maestro and its CEO have admitted to intentionally submitting inflated medical bills to MassHealth and, in particular, defrauding the program in the following ways.

Improperly Billing MassHealth

Maestro billed MassHealth for care that was never provided and for care that was medically unnecessary. Additionally, the provider was billing the state for care and care plans that physicians had never reviewed or authorized.

Creating “Phony” Medical Records

Maestro falsified medical records to try to make it seem as though their services had met Medicare’s reimbursement criteria. Creating this second-level of documentation to back-up and attempt to legitimize the medical bills sent to MassHealth was just one of the additional layers of complexity in this case.

Failing to Comply with the 6-Year Record Retention Requirements

Maestro did not retain records verifying that physicians had reviewed care plans or that care was medically necessary. MassHealth requires home health care providers to maintain these records for at least six years after claims have been submitted to the state for reimbursement.

The Settlement Agreement

In addition to paying the $10 million settlement, Maestro and CEO George Kiongera have agreed to hire an independent monitor to manage a 3-year compliance program that will oversee all of the agency’s facilities. The terms of the settlement also require Maestro to revamp its policies and procedures, provide new training for staff, and conduct annual audits, at the oversight of the independent monitor.

How Medical Records Are Used to Prop Up & Take Down Medicare Billing Fraud Schemes

Maestro’s case resonates as a prime example of a complex Medicare fraud scheme and highlights how the medical record itself is often the smoking gun. By constructing its complicated billing fraud scheme on manipulated, manufactured, and “lost” records, Maestro also left behind clues of wrongdoing through those very same records—including the ones it failed to retain or perhaps never had.

While authorities have not disclosed specifics regarding how Maestro falsified or manipulated medical records, Medicare fraud billing schemes like this one often involve records that:

  • Are illegible or contain odd addendums
  • Do not contain physician signatures on patient care plans
  • Omit key details about a patient and/or their medical history
  • Have inconsistencies regarding patient care plans, lab reports, diagnostic codes, and/or medical billing codes
  • Detail illogical or impossible timelines for screenings, tests, services, care, or treatment
  • Fabricate results without documentation of the proper diagnostic testing to confirm

Whether this case and its multi-million-dollar settlement will deter other home health care providers from future Medicare billing fraud schemes remains to be seen. Regardless of the impacts, medical records and the experts who can decipher them will continue to play critical roles in Medicare billing fraud investigations and cases for the foreseeable future.

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