Description: Hammond, Indiana qui tam lawyers represented the Defendant accused of fraudulently billing the Indiana Medicaid program.

The Government claimed that Edgewater Systems for Balanced Living, Inc., a healthcare provider in Gary, Indiana that provides mental health services, for fraudulently billing the Indiana Medicaid program.

The Indiana Medicaid program provides healthcare for low income, often uninsured, Indiana residents who cannot otherwise afford needed medical care. Indiana Medicaid is jointly funded by the United States and the State of Indiana. The case involves Indiana Medicaid’s requirement that, before conducting, and billing Indiana Medicaid for, mental health counseling sessions, the provider first must draft an Individualized Integrated Care Plan (Care Plan), and the Care Plan must be signed and approved by either a physician or a Health Service Provider in Psychology, which is a provider with a Ph.D. Degree in Psychology. Despite knowing of the requirement because of negative Indiana Medicaid audits during prior time periods, during the period from November 1, 2012 through and including December 31, 2017, Edgewater repeatedly billed Indiana Medicaid for mental health counseling sessions that failed to meet the requirement.

The False Claims Act prohibits an entity from knowingly submitting claims for payment to a Medicaid program that fail to comply with required billing standards. Under the False Claims Act such non-compliant billing constitutes a fraudulent claim even though services were in fact rendered. Edgewater has agreed to pay the United States and the State of Indiana $1.25 million for falsely billing Indiana Medicaid for the mental health counseling sessions.

The settlement was reached as a result of an investigation initiated by United States Attorney’s Office for the Northern District of Indiana with assistance from the Indiana Medicaid Fraud Control Unit within the Indiana Attorney General’s Office. Assistant United States Attorney Wayne T. Ault handled the settlement negotiations.

Outcome: Defendant agreed to pay $1.25 million to settle the claims made against it.

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