AG Healey Sues Home Health Agency for Providing Services Without Physician Authorization - Mass.gov

BOSTON — As part of an ongoing effort in Massachusetts to address fraud, waste, and abuse in the home health industry, Attorney General Maura Healey announced a lawsuit against a home health agency for allegedly falsely billing the state's Medicaid program, MassHealth, for services that were not authorized by a physician and/or not medically necessary.

The lawsuit – filed Tuesday in Suffolk Superior Court against Prestige Health Care Services, Inc., its owner and CEO Isdory Lyamuya, and its Chief Operating Officer Augustus Kormah – alleges that the defendants were aware that many Prestige patients lacked a physician authorization certifying that the services Prestige purported to provide were medically necessary, yet they continued to bill MassHealth for services anyway.

"Home health care services assist low-income individuals with activities of daily living, and our office is committed to rooting out fraud within this industry," said AG Healey. "We allege this agency repeatedly and knowingly billed MassHealth for unauthorized services and are seeking to hold them accountable to ensure our health care dollars are spent appropriately."

MassHealth pays for three kinds of home health care services for eligible members – nursing, home health aide, and therapy (physical, occupational, and speech/language). To bill MassHealth for any of these services, the member's physician must review and sign a Plan of Care (POC) certifying that home health services are medically necessary.

According to the AG's complaint, Prestige began providing services to patients who did not require services and continued to service patients after they no longer required skilled nursing services. In some instances, physicians did not authorize the services listed in the POC, some returning the POC with notations such as "services not needed." If Prestige received such a rejection, the AG alleges that Prestige often shredded the document and tried to re-submit it for authorization again. According to the complaint, employees raised concerns with both Lyamuya and Kormah about billing MassHealth without physician-authorization, but no changes were made to the company's practices. One employee was allegedly fired a day after she told Lyamuya and Kormah that she was not comfortable billing MassHealth without enough information.

As a result of an audit finding missing physician authorizations for 70 percent of Prestige's patients, MassHealth withheld further payment to Prestige as of July 26, 2019 and terminated Prestige as a provider on July 29, 2019.

The AG's lawsuit alleges violations of the Massachusetts False Claims Act, the Medicaid False Claims statute, and the common law, and seeks treble damages and civil penalties.

The litigation is being handled by Assistant Attorney General Scott Grannemann and Investigator Thomas Barreca of AG Healey's Medicaid Fraud Division, with substantial assistance from MassHealth.

The AG's Medicaid Fraud Division receives 75 percent of its funding from the U.S. Department of Health and Human Services under a grant award. The remaining 25 percent is funded by the Commonwealth of Massachusetts.

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