1. Virginia Attorney General Health Care Fraud and Elder Abuse Section
Investigating and Prosecuting Health Care Fraud and Elder Abuse May 8, 2019 Nicole Terry Assistant Attorney General – Medicaid Fraud Control Unit

2. Overview Who we are: History, Duty, and Capability
How we work: Coordinated Investigations – FBI, HHS-OIG, IRS, Local Law Enforcement, DEA, VSP
What we’ve done: Abuse/Neglect; Health Care Fraud; False Statements; Alteration of Records; Agg. I.D. Theft; Prosecuting Abuse as Fraud Cases

3. Who we are
In 1982, the General Assembly created the MFCU to investigate fraud and abuse committed against the Virginia Medicaid program.
“The unit will also review complaints alleging abuse or neglect of patients in health care facilities receiving payments under the State Medicaid plan and may review complaints of the misappropriation of patient’s private funds in such facilities.” 42 C.F.R. § (b)(1)
“[T]he Attorney General or his authorized representatives shall review complaints alleging abuse or neglect of persons in the care or custody of others who receive payments for providing health care services under the state plan for medical assistance.” Va. Code Ann. §

4. Who we are Approximately 47 full-time investigators
Two Nurse Investigators
Investigators with federal and state criminal investigative experience and former Adult Protective Services workers
Seven prosecutors and 14 civil attorneys
Four offices: Richmond; Fairfax; Roanoke; Abingdon
2019 – Approximately 100 unit employees, three main components:
Criminal Provider fraud; Elder Abuse and Neglect; Civil Litigation.

5. Who we are – what we investigate
Billing for services not performed
Billing for unnecessary services or tests
Embezzlement
Kickbacks
Inflating bills for services provided
Double-billing
Drug Diversion

6. Who we are Coordinated, multidisciplinary investigations
AG, Local law enforcement, VSP, USAO, FBI, HHS-OIG, DEA, FDA, IRS, Va. Tax, DMAS
2014 Inspector General’s award for Excellence in Fighting Fraud, Waste, and Abuse
: 41 convictions; $19,551, in court-ordered civil and criminal recoveries
: 27 convictions; $14,112, in court-ordered civil and criminal recoveries

7. Who we are The Elder Abuse and Neglect Squad was formed in 2008.
The unit investigates single victim/single actor abuse and neglect of incapacitated adults committed by health care providers.
The unit also investigates corporate neglect in health care facilities.

8. How we work – Identifying Relevant Material
Witness interviews
Identifying potential witnesses:
DMAS Audit; Provider contract; SCC records; Employment records; Licensing inspections; VDH nursing home inspections; DMV records; complainants
Medical records
State regulatory inspections/audits
Subpoena authority
Audit and inspect authority
Billing history
Number of patients
Amount billed
How long they have been a provider

9. Criminal Case Studies
Fraud cases: United States v. Deborah Branch, Bryan Harr Sr., and Melissa Harr Drug Diversion cases: United States v. Dwight Bailey MD

10. United States v. Branch, B Harr, and M Harr
Criminal Case Studies
United States v. Branch, B Harr, and M Harr
Referred to the MFCU by Bristol Department of Social Services
Personal and Respite Care for Evan Harr living with Cerebral Palsy and Kawasaki’s Disease, unable to communicate
Evan and his two younger brothers were kept locked in an upstairs bedroom- two mattresses on the floor, covered in feces, not light, no electricity, and the only window was broken by the boys attempt to escape
Evan’s Parents Bryan Sr. and Melissa convicted of three counts of cruelty to a child

11. Criminal Case Studies Branch and Harr (cont.)
Branch billed up to 12 hours per day for Evan’s care
Branch paid the parents $400 cash per month to sign the fraudulent timesheets
Medicaid paid $350, to the fiscal intermediary who then paid Branch $207,854.43
All three pled guilty in federal court to Conspiracy to Commit Healthcare Fraud

12. Criminal Case Studies Branch and Harr (cont.)
Branch was sentenced to 72 month federal incarceration and three years probation
Bryan Harr Jr. was sentenced to 48 months federal incarceration to run consecutive with four years state incarceration and three years probation
Melissa Harr was sentenced to 48 month federal incarceration to run consecutive with three years state incarceration and three years probation
All defendants are responsible for $350, in restitution

13. United States v. Dwight Bailey MD
Criminal Case Studies
United States v. Dwight Bailey MD
Joint Investigation: MFCU, DEA, Virginia State Police
Bailey was prescribing drugs outside of the scope of a legitimate doctor-patient relationship
The Board of Medicine suspended Bailey’s license after finding Bailey to be a danger to the health and welfare of his patients and the public
The suspension was based on the treatment of nine patients who Bailey prescribed drugs
Five of the nine patients fatally overdosed between July 2010 and November 2011
In August 2014 DEA, MFCU, and VSP executed a S/W at Bailey’s practice, office, and residence

14. United States v. Dwight Bailey MD
Criminal Case Studies
United States v. Dwight Bailey MD
After a lengthy trial Bailey was found guilty of 59 counts of Distribution of Controlled Substances, three counts of Conspiracy to Distribute Controlled Substances, and one count of Maintaining a Premise for the Purpose of Distribution of Controlled Substances
Bailey was sentenced to 151 months of federal incarceration, two years probation, ordered to pay $25,000 fine, and $6,300 special assessment

15. Prosecuting Elder Abuse as Fraud Cases
Mixed results prosecuting cases as Abuse or Neglect of an Incapacitated Adult
The statute is cumbersome; tendency to not second-guess care givers
False Statements relating to health care matters
Health care fraud (10 year max penalty)– enhanced penalty: If the violation results in serious bodily injury … such person shall be fined under this title or imprisoned not more than 20 years, or both; and if the violation results in death, such person shall be fined under this title, or imprisoned for any term of years or for life, or both.
Still attack the injury or suffering – but approach the investigation and prosecution from a different perspective

16. Summary Who we are: History, Duty, and Capability
How we work: Coordinated Investigations – AG, Local Law Enforcement, VSP, FBI, HHS-OIG, DEA, FDA, IRS
What we’ve done: Abuse/Neglect; Health Care Fraud; False Statements; Alteration of Records; Agg. I.D. Theft; Prosecuting Abuse and Drug Diversion as Fraud Case