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PCS Providers Sentenced for Medicaid Fraud

Release Date: June 18, 2010
Contact: Brad Deen, 919-733-9190

RALEIGH — Two Personal Care Services providers in western North Carolina have been sentenced to nearly four years in prison for Medicaid fraud.

Kristie Brake and Kimberly Miles, co-owners of Heritage Home Care in Sparta, pleaded guilty in Federal Court last month, ending a multiyear investigation and prosecution that involved nearly 16,000 fraudulent Medicaid claims. The pair were sentenced Tuesday to 46 months imprisonment each and ordered to repay Medicaid more than $600,000.

Personal Care Services (PCS) is a Medicaid program intended to provide in-home assistance to people with a disability that interferes with daily activities such as bathing, dressing, meal preparation, toileting or mobility. An investigation launched by the Division of Medical Assistance (DMA) Program Integrity unit, and taken over by the Medicaid Investigations Unit within the N.C. Attorney General’s Office, found that Heritage:

  • Claimed to provide PCS to a recipient who had died.
  • Billed for a recipient who had moved hundreds of miles away from Alleghany County.
  • Falsified in-home aides’ time sheets.
  • Submitted fraudulent nursing assessments.
  • Forged physician signatures.
  • Paid close relatives of PCS recipients to be their in-home aides.
  • Paid bonuses to aides for referrals of PCS clients.

Brake and Miles submitted 15,833 fraudulent Medicaid claims totaling $622,405.89, all of which the U.S. District Court for Western North Carolina on Tuesday ordered to be repaid. DMA has terminated Heritage from billing N.C Medicaid.

DHHS Secretary Lanier Cansler said he was “thrilled” at the outcome of the case, but he noted Heritage “is only one of a number” of Medicaid fraud cases in various states of investigation or prosecution.

“More than just the blatant illegality, what’s troubling is that every dollar these people stole from taxpayers is a dollar that could have been spent to provide health care to someone who needs it and who follows the rules,” Cansler said. “We are in the midst of a budgetary struggle that has every agency in state government, including Medicaid, tightening their belts. How badly is that $600,000 needed right about now?”

DHHS has been working with an independent agency to assess all PCS recipients and to ensure appropriate levels of service. The Department has also begun targeting Medicaid fraud, waste and abuse more aggressively, including a partnership with IBM that uses sophisticated computer analysis to identify suspicious claims. To further investigate and prosecute offenders, current budget proposals would add staff to the Attorney General’s Medicaid Investigations Unit.

DHHS is also asking the public’s assistance in reducing Medicaid waste. A public awareness campaign titled “Medicaid fraud and abuse cost YOU!” asks Medicaid recipients, providers or members of the general public who suspect Medicaid fraud to report it to DMA via a toll-free number, 1-877-DMA-TIP1 (1-877-362-8471). DHHS is also getting out the message that failure to report suspected Medicaid fraud and abuse could result in a civil penalty.

The public campaign and tip-line, launched in mid-May, have already caused a 33 percent spike in Medicaid fraud reports over the same period last year. “DHHS takes even anonymous tips seriously,” said Cansler, “as they can have important consequences.  A concerned citizen’s tip led to the Heritage PCS case.”