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Private Health Care Provider Settles Over Massive Fraud Scheme

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Newscom

On top of issuing billings for services not rendered, the DoJ says the company's officers subverted federal quality standards by falsifying documentation pertaining to the supervision, training, and qualifications of caregivers. The investigation also revealed that thirteen of Maxim's offices - part of national network that numbers in the hundreds - were unlicensed by state or federal authorities. Billings for care provided by these unlicensed offices was routinely funneled through the company's licensed offices, effectively evading the scrutiny of Medicaid and VA auditors.

The DPA absolves Maxim's liability under the Federal False Claims Act for false billings issued to the government programs, on the condition that the company pay $130 million to the federal government and 42 states affected by the fraud.

While the agreement allows Maxim to avoid conviction on charges of health care fraud, it requires the company to pay out up to $150 million in criminal and civil penalties. The Maryland-based health care provider must also implement a series of internal reforms, including the replacement of its executives, the hiring of a Chief Compliance Officer, and total reform of its compliance system. Maxim must also terminate employment for the eight employees who entered individual plea agreements with the DOJ on felony fraud charges.

Although the massive fraud scheme goes back to at least 2003, Maxim received accreditation from the Accreditation Commission for Health Care (ACHC) in January, 2008. The ACHC explained its accreditation of Maxim in a press release:

"Maxim is a full-service healthcare company that has earned the reputation of providing innovative solutions that improve health and enhance the quality of life for its patients. Their dedication to customer service and improving patient care, combined with a commitment to staffing quality healthcare professionals has made Maxim one of the most dependable healthcare companies in the country."

The ACHC, a private, not-for-profit organization, has to date not issued a press release regarding its accreditation of Maxim. Who accredits the accreditor is another story. In 2010, the International Organization for Standardization re-certified the ACHC's Quality Management System.

Maxim's malfeasance first came to light after after Richard West, a New Jersey native and Medicaid patient who suffers from muscular dystrophy, filed a whistleblower lawsuit in 2004. According to the Asbury Park Press, in 2003, West attempted to contact New Jersey Medicaid's hotline after noticing Maxim had overbilled Medicaid by 700 hours. Although West never received a response from the agency, he will be collecting a $15 million "relator award" for his part as a whistleblower.

Although the U.S. Attorney's Office did most of the heavy lifting during the multi-year investigation, New Jersey's Attorney General Paula Dow fired out a press release ahead of the DOJ's press conference. J. Gilmore Childers, the First Assistant U.S. Attorney for the District New Jersey quickly rebuked Dow saying the state "played a limited administrative role in this case." Childers added, "It is troubling and disappointing that they would take credit for years of tireless work done by federal agents and prosecutors."