In November of 2019, the Pennsylvania House Government Oversight Committee released a report detailing rampant Medicaid fraud happening across the state, as well as recommendations from a Grand Jury for new laws to combat this growing problem. In response, Pennsylvania’s Commonwealth Fraud Prevention Act was passed in the summer of 2020, which makes the filing of false records and claims by health care providers and other federal contractors a criminal act. The legislation also (1) requires state agencies to analyze their susceptibility to improper payments; (2) creates a state-level “Do Not Pay” system to stop improper payments before they are made; (3) establish requirements for contracts with Medicaid Care Organizations; and (4) increase penalties for fraudulent claims.
Since the passing of this legislation, Pennsylvania officials, led by Attorney General Josh Shapiro, have been actively fighting numerous claims of Medicaid fraud, which have been a problem in the state since long before its first outlines of legislation.
In June 2021, Attorney General Josh Shapiro charged four Philadelphia business owners in a $10 million Medicaid fraud case. The businesses revolved around a program called Community Health Choices, a transportation service that assists the elderly and disabled. The suit also named the owners of three service coordination agencies – Brighter Care Services LLC, Pennsylvania Service Coordination Agency, and Pennsylvania Development Agency – who were all charged with the overbilling of $7.9 million in nonmedical transportation services that were never provided to their clients.
From 2017-2019, the three service coordination agencies billed the $7.9 million for 1,712 trips with Rides Your Way LLC, which is equivalent to $4,614 per ride. If billed at the authorized rate of $35 per ride, the total cost would have been $59,920. Two of the agencies, Brighter Care Services and Pennsylvania Service Coordination Agency, also charged for far more services than they could have physically provided, defrauding Medicaid of an additional $2 million.
Officials warn of continued fraud, citing the hundreds of arrests and convictions from the last few years alone as proof that more work is needed to address the growing numbers. The Pennsylvania Department of Human Services asks that concerned citizens file reports for suspected Medicaid fraud by calling the tipline at 1-844-DHS-TIPS, or file a report using the online form provided on their website.