Oct 6, 2011

Hialeah Medicaid provider overbilled by One Million Dollars.

Ruth Reveron used her Hialeah rehabilitation center to fraudulently overcharge Medicaid by more than $1 million before authorities caught on, terminated her participation in the state-run medical program and turned her case over to Florida’s attorney general, prosecutors say.

But here’s what the Agency for Health Care Administration, which administers the Medicaid program, missed:

Nine months after Reveron’s censure, her clinic — T&R Diagnostic and Rehab Center — remained open, and continued to successfully bill Medicaid up until her arrest in early September.

Reveron’s days in the physical therapy business appear over. She sits in a Miami jail cell, charged with Medicaid fraud and grand theft for heading up the long-running scheme, according to state investigators. But son Luis Yance, who the state claims participated in his mother’s scam, has not been charged. He now runs his own rehab center in the same office building that held Reveron’s now-defunct clinic.

Reached by phone Thursday, Yance was asked how T&R was still able to operate after the state handed down the 20-year Medicaid ban: “I think that’s a question you’ve got to ask Medicaid. If it was open for so long, I guess they never had a problem with it.”

AHCA, which confirmed that T&R was able to wrongly charge the state even after its sanction, has a different take.

Following Reveron’s final expulsion from Medicaid in late 2010, she ran an end-round past AHCA’s oversight outfit by simply requesting a new provider number through the Agency for Persons with Disabilities, the state-run program tasked with serving the needs of those with conditions such as autism and cerebral palsy.

Through this state agency, Reveron gained clearance as a Home and Community Based Services Waiver provider.

After that, it was business as usual.

T&R’s clinicians, never made aware of Reveron’s sanction, continued to treat Medicaid patients, and the state continued to reimburse.

It wasn’t until a routine follow-up meeting did a representative of the Bureau of Medicaid Program Integrity identify the second provider number, and notify the attorney general’s Medicaid Fraud Control Unit.

Still, Reveron remained in business until her arrest last month, when MPI moved to terminate that additional account.

This gap in enforcement was open to exploitation, AHCA acknowledges, and the agency has since moved to close the loophole, spokeswoman Shelisha Coleman said.

At the time of T&R’s original audit in late 2009, AHCA did not require a check of the Medicaid Management Information System to determine if the offending party had created any other provider numbers during the course of the inquiry.

But that’s changed in the two years since, Coleman added.

It is now standard operating procedure to flag not just the primary Medicaid number, but all associated provider accounts.

“Once a provider number had been terminated in the Medicaid Management Information System, the system will not pay any future claims for dates of service subsequent to the termination date,” Coleman added.

That’s bad news for the therapists who worked in good faith through T&R at the time of Reveron’s arrest. Unaware of Reveron’s extracurricular activities, they likely will never be paid for two months worth of work.

Read more: http://www.miamiherald.com/2011/10/06/2442441/hialeah-clinic-finds-loophole.html#ixzz1a3yi7iur