The following cases highlight fraud, waste, and abuse (FWA) and serve as a reminder to uphold high ethical standards when providing patient care and services.
Bethel Psychologist Charged With Medicaid Fraud
A 76-year-old man was arraigned on four counts of felony Medicaid fraud.
The charges brought against him by the Attorney General's Medicaid Fraud and Residential Abuse Unit (MFRAU) stem from an investigation into his work as a licensed psychologist. The investigation, conducted by MFRAU and the Secretary of State's Office of Professional Regulation, began after a referral was received from the Department of Vermont Health Access due to concerns with this man's overall therapeutic and billing practices.
The investigation found that he had submitted claims for payment to Vermont Medicaid for psychotherapy sessions he had not provided, defrauding Vermont Medicaid of over $600,000 in public healthcare funds. He also failed to maintain patient records as agreed in his Medicaid Provider agreement and as required by state law and federal law.
He pleaded not guilty at his recent arraignment in Vermont Superior Court, Windsor Criminal Division. The judge ordered him to be released on his own recognizance on the condition that he present himself to Vermont State Police for fingerprinting within seven days.
The Attorney General's Office emphasizes that individuals charged with a crime are legally presumed innocent until their guilt is proven beyond a reasonable doubt in a court of law.
Source: Bethel Psychologist Charged with Medicaid Fraud. (2025, October 1). www.ago.vermont.gov
AG Sunday: Philadelphia Pharmacy Pleads Guilty, Will Pay $2.3M Restitution for Medicaid Fraud Scheme Involving Unregulated HIV Meds
AG Sunday announced that a Philadelphia pharmacy will pay more than $2 million in restitution after pleading guilty to felony Medicaid Fraud and theft charges related to the dispensing of unregulated HIV medications.
The Office of the Attorney General's Medicaid Fraud Section charged the company earlier this year for its role in a multi-million-dollar scheme to defraud the Medicaid and Medicare programs through reimbursements of HIV medications.
The investigation revealed that HIV medications—an estimated 100,000 tablets—dispensed from the pharmacy were not from legitimate wholesale suppliers.
”The distribution of life-saving medications is appropriately strictly regulated. This company put profits over their patients and broke the law to ignore those regulations for their own benefit,” Attorney General Sunday said. “I commend our Medicaid Fraud Control Section and our partners with the Department of Health and Services for a meticulous investigation that led to the stoppage of these unregulated sales and the recovery of millions of dollars that will benefit underserved citizens.”
The investigation found no evidence of individuals who experienced physical harm or illness due to these dispensed medications.
The group's owner and pharmacist, as part of the plea resolution, is prohibited from being a Medicaid/Medicare provider for at least five years, and his pharmacist license will be suspended for that same period.
The man's six other pharmacies in the area have since closed.
Agents interviewed pharmacy employees said that the owner was acquiring expensive HIV medications from a source other than one of legitimate wholesale drug suppliers and putting them on the shelf to be dispensed to patients. The employees described the bottles as “sticky” to the touch, as if labels had been removed from the bottles.
Source: AG Sunday: Philadelphia Pharmacy Pleads Guilty, Will Pay $2.3M Restitution for Medicaid Fraud Scheme Involving Unregulated HIV Meds. (2025, October 1). www.attorneygeneral.gov
Three Charged With Medicaid Fraud in Alleged Transportation Scheme
A 51-year-old woman was arraigned for allegedly exploiting a Medicaid transportation program. She has been charged with 10 counts of Medicaid Fraud – False Claim, each a four-year felony. Two other women were also arraigned for allegedly defrauding the same program. They each face five counts of Medicaid Fraud – False Claim.
The Michigan Medicaid program will provide mileage reimbursement to enrolled beneficiaries when they travel to eligible medical appointments. In some cases, a smartphone app is made available to track mileage to these appointments using the built-in GPS of the phone. When a trip is complete, the reimbursement payment is added to a payment card mailed to the beneficiary when they register for this program. The card can then be used like any debit card.
It is alleged that the defendants participated in a scheme where another app was used to effectively trick a phone into thinking it was someplace it was not, and submitted reimbursement requests for trips that never took place. This matter was referred to the Department of Attorney General by the Michigan Department of Health and Human Services, Office of Inspector General (DHHS-OIG).
All three women were granted a $50,000.00 personal recognizance bond and were scheduled to be due in court.
For all criminal proceedings, a criminal charge is merely an allegation. The defendant is presumed innocent unless and until proven guilty.
Source: Three Charged with Medicaid Fraud in Alleged Transportation Scheme. (2025, October 9). www.michigan.gov
Eight Medicaid Providers Indicted, Accused of Phantom Billing
Ohio Attorney General Yost continues to bust Medicaid providers who bill fraudulently, highlighted by recent indictments accusing seven people and one business of submitting claims for made-up services. The Medicaid Fraud Control Unit, an arm of Yost's office, investigated the cases and secured the indictments in Franklin County Common Pleas Court. The cases include two people who billed for in-home services when clients were incarcerated, a home-health aide who engaged in a kickback scheme, and a provider who admitted to submitting false claims using her husband's name.
“If you sneak extra Medicaid dollars like Halloween candy, don't be surprised when the consequences leave a bitter taste,” Yost said. “Save your tricks for trick-or-treat night.”
Among those indicted:
The first woman is accused of billing for services when she was traveling or working another job, and when a recipient did not live at the address listed on claims. She also admitted to submitting fraudulent timesheets using her husband's name. Investigators calculated a $27,465 loss to the Ohio Medicaid program.
The second woman allegedly submitted timesheets for home-health services while the recipient was on vacation, leading to a $1,593 loss for Medicaid. The client told investigators that she confronted her after the trip to demand that she sign the fraudulent timesheets.
A third woman was charged after investigators determined that she participated in a kickback scheme and received $2,613 that she was not owed.
The fourth woman was indicted on one count of Medicaid fraud. From May 2024 through April 2025, she allegedly billed for in-home services while recipients were receiving care from family members or participating in programming outside the home. Investigators calculated a $34,028 loss to Medicaid.
A fifth man and his defunct business were each indicted in a case involving a $17,727 loss to Medicaid. The defunct business paused its adult day care services in late 2022 for a planned relocation. Although it never resumed operations at the new address, the business allegedly continued to bill Medicaid for services.
The sixth woman allegedly billed for in-home services while the client was in jail, representing a $2,403 loss to Medicaid.
And finally, the seventh woman discontinued services for a client in May 2024 but allegedly continued to bill Medicaid for another month. An investigation also found that she billed for services when she was traveling in Florida or working a different job and when a client was incarcerated. In total, $14,580 was fraudulently billed to Medicaid.
Indictments are criminal allegations. Defendants are presumed innocent unless proved guilty in a court of law.
Source: Eight Medicaid Providers Indicted, Accused of Phantom Billing. (2025, October 16). www.ohioattorneygeneral.gov
Sonal Patel, BA, CPMA, CPC, CMC, ICDCM, is CEO and Principal Strategist of SP Collaborative, LLC. Sonal has over 13 years of experience understanding the art of business medicine as a nationally recognized thought-leader, speaker, author, creator, and consultant to elevate coding compliance education for the business of medicine.
www.spcollaborative.net
