20 August 2024. When it comes to billing practices, it seems these clinics took a wrong turn at the “crossroads.” Greenville, South Carolina-headquartered substance use disorder treatment centers serving patients in Virginia entered into a settlement with the United States and the Commonwealth of Virginia. The four clinics collectively known as Crossroads paid $863,934 to resolve allegations that they submitted false claims to Medicaid. A former Director of Network Management and Contracting for the treatment centers reported these false claims under the qui tam provisions of the False Claims Act. The whistleblower will receive over $60,000 or approximately 17% of the federal recovery as a reward.

Allegation Details

Crossroads clinics treat patients with opioid use disorder. According to the allegations, these clinics knowingly overbilled Virginia Medicaid from 2016 through mid-2023 by submitting claims with code 99215 for meetings that did not meet the criteria of that code. This code is meant for meetings involving both a comprehensive medical history and medical examination, as well as high complexity medical decision making. The meetings the clinics referenced with this code were routine check-ins instead of the more intensive meetings coded with 99215. By knowingly submitting claims for services not rendered to a government-funded healthcare program, the clinics allegedly violated the False Claims Act.

How Medicaid is Funded

Medicaid is funded through a partnership between federal and state governments. The federal government provides matching funds to states based on their Medicaid expenditures, with the Federal Medical Assistance Percentage (FMAP) determining the federal share, which varies by state. States contribute their own funds to cover the remainder of Medicaid costs. Additionally, states have the flexibility to expand coverage and services within certain federal guidelines, which can affect overall funding and program scope. This collaborative funding structure allows Medicaid to provide crucial health services to low-income individuals and families across the United States. In this settlement, the clinics paid $356,891 to the United States and $507,043 to the Commonwealth of Virginia.

The Role of Whistleblowers

Diana France, a former Director of Network Management and Contracting for Crossroads, was the whistleblower in this case. She is set to receive $60,671 as her share of the federal recovery, and will also receive a portion of the Commonwealth’s recovery. Because of Medicaid’s state and federal funding, whistleblowers who report Medicaid fraud may receive rewards from state and federal governments. The Special Agent in Charge with the Department of Health and Human Services Office of Inspector General said about the case, “Submitting false claims to Medicaid undermines the integrity of the program and wastes valuable taxpayer dollars.” Whistleblowers, whether competitors or insiders, ensure Medicaid funding goes towards its intended purpose: providing healthcare for economically disadvantaged individuals.