Department of Health care

Medicaid Fraud in California Courts

Rehab Racket: the Sequel
California’s County-Level Judicial Branch Medicaid Oligarchy

A Family Court Accountability Coalition Special Investigative Report
By Ron Pierce

Alleged Medi-Cal Billing Fraud Unearthed in California at County Level.

The California Medical Assistance Program known as “Medi-Cal” is the California Medicaid welfare program serving low-income individuals, including families, seniors, persons with disabilities, children in foster care, pregnant women, and childless adults with incomes below 138% of federal poverty level.

Jointly administered by the California Department of Health Care Services (DHCS) and the federal Centers for Medicare and Medicaid Services (CMS), its many services are implemented at local level by California counties. Approximately 12.5 million Californians are enrolled in Medi-Cal as of May 2015, about 32.4% of the state’s population.

Recently, California’s drug rehabilitation program came under fire subsequent to a 2013 joint investigation between CNN and the Center for Investigative Reporting, which uncovered fraudulent Medi-Cal billing schemes by drug rehab centers who were billing for “ghost clients” and teens who did not have addictions.

Rehab Racket discovered that drug rehab counselors fabricated accounts of therapy sessions and diagnosed teens with addictions they did not have. Rehab operators bribed vulnerable people with cash and cigarettes to attend taxpayer-funded drug rehabilitation sessions.

Around the state, drug Medi-Cal clinics submit bills and regularly receive payment from California counties within weeks. State and county auditors discover taxpayer money has been squandered only if they later review the clinics’ client charts.

Unfortunately, a state audit found that county oversight was so lax, that California’s Medi-Cal agency is purportedly launching an overhaul of drug rehabilitation programs in light of a damning internal audit that spotlights ham-handed oversight and confirms many findings of CNN/CIR’s year-long investigation.

After weeks of silence, the DHCS jumped into action, dispatching audit “strike teams” to drug Medi-Cal rehabilitation facilities throughout California, eventually cutting off funding to more than 200 clinic sites. Auditors forwarded their findings to the state Department of Justice, leading to 11 people charged and nine convicted for Medi-Cal fraud.

The California Courts Connection

However, what remains unaddressed in the days after Rehab Racket are the contractual relationships these county program drug clinics maintained with local county agencies in their provision of and billing for court-ordered drug rehabilitation; financial relationships with the county mental health agency networks that possibly explains the lack of oversight revealed.

Part One

Part Two

Part Three

Counties Financial Interest in Controlling Medi-Cal Administration

Each California county offers Medi-Cal mental health services termed Therapeutic Behavioral Services (TBS). Usually these services are administered by the same county mental health agencies proliferating California’s FCS network.

Where Medi-Cal services for children are “school-based”, local court experts and family court judges predictably steer custody and visitation in a manner that forces parents to pay for services they do not need, while ensuring their children attend school in the controlling county. This is no accident.

The Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program is Medicaid’s comprehensive and preventive child health program for individuals under the age of 21. According to DHCS, the School-Based Medi-Cal Administrative Activities (SMAA) program “reimburses school districts for the federal share (50%) of certain costs for administering the Medi-Cal program.”
The Medicaid statute also requires that states provide any medically necessary health care services listed in Section 1905(a) of the Social Security Act to an recipient even if the services are not available under that state’s Medicaid plan to the rest of the Medicaid population.

Similarly, private, non-profit corporation networks in each county, in contractual agreement with those counties to provide court-mandated services for divorcing litigants and children, often share a similar financial arrangement where counties match federal funding that local contracted clinics rake in.

The Administrative Office of the Courts has provided for each superior court to act as a depositor for the AOC pursuant to Government Code § 68085.9, and much of the public funds that California courts collect, after being locally deposited and harvested for interest dividends, eventually find their way into each county’s Children’s Trust Fund.

The accrued interest is divided equally between the local county and court, while the original quarterly principal is transferred to the State Controller’s office where it is funneled through a hive of judicial branch accounts such as the Trial Court Judges Retirement Fund (see 68085.1(e)(1)); demonstrating a direct link between forced participation in judicial branch services through local county clinic networks – and judicial retirement benefits. This obviously highly prejudicial “padding” of judicial retirement benefits is reminiscent of Judicial Watch’s current battle with the California judiciary over similar issues.

In an atmosphere of such saturated cronyism, it is entirely probable that family law cases are being manipulated by county mental health agency networks and corrupt judges toward harvesting as much federal funds from these cases as the county can collectively draw.

In looking for evidence of such manipulation, it is noteworthy to again reference the CRC article, “Making Divorce Pay”, where it already exemplifies a family law case in California that is replete with factual indicators showing manipulation by county facilitators for Medi-Cal billing interests likely has occurred.

Take Charles Paclik’s divorce, which started in Illinois in 2006. After his ex-wife moved to California, the jurisdiction for the divorce moved with her. […] After that testimony, the court ruled Paclik and his ex-wife should have shared parenting. He lost primary contact with his children again after his wife’s moved to an adjacent county in 2013 [which] triggered another custody fight. Paclik’s custody continues to be litigated nine years after it began.

Since the article’s publication, the Paclik case has taken a turn more closely resembling the Medi-Cal fraud unearthed in Rehab Racket; again suggesting that investigation did not go far enough in probing the larger issue of fraudulent enrichment off of Medi-Cal billing at county level.

In late 2013, impoverished by nine years of unending divorce litigation, Mr. Paclik relocated from Alameda County, California to Fresno County, California for economic reasons. Contemporaneously, he enrolled his children in the local school district he had moved to.

However, despite SMAA guidelines, which would have then shifted to Fresno County, Contra Costa County refused to relinquish control over his children’s Medi-Cal benefits regardless.

In November of 2013, coinciding with his relocation to Fresno County, Mr. Paclik requested inter-county transfer (ICT) of his Medi-Cal benefits from Alameda County to Fresno County, including transfer of his children’s Medi-Cal benefits from Contra Costa County to Fresno County as well. However, instead of transferring his children’s Medi-Cal benefits as requested, his “inter-county transfer” request was inexplicably put on hold – for over a year.

During that delay, Mr. Paclik’s custody and visitation were inexplicably modified, effectively changing the parameters of his standing to request Medi-Cal ICT.

After numerous phone calls to Medi-Cal regarding the delay, Mr. Paclik subsequently learned that the clinicians, imposed into his parent-child relationship at the county level by Contra Costa Superior Court and its FCS, were billing his children’s Medi-Cal for provision of their court-ordered services – services that his children have reported to law enforcement that they do not receive.

Instead, his children report these clinicians routinely attempt to indoctrinate them into the belief their father is abusive and mentally ill. Where his children have consistently resisted these attempts at programming, they now report these same court-ordered clinicians simply park them in a room with toys and games while their mother is interviewed instead.

As with most other family law cases, the reports these county-connected clinicians then render to the family court often play a vital role in its restructuring of Mr. Paclik’s custody and visitation. Where both Mr. Paclik and his children resist the behavior modification imposed upon them by AFCC-controlled county interests, their time together has been predictably restricted.
In February of 2014, three months after his request for ICT, Mr. Paclik found himself inexplicably summoned back to family court where his custodial time was summarily decreased by one day; tipping the scales of primary custody to the Contra Costa County-based mother.

In July of that same year, that same family court judge ordered his children summarily disenrolled from Fresno County – reenrolling them in Contra Costa County via ex parte order – no hearing or service; thus, providing legitimacy after-the-fact for Contra Costa County Medi-Cal agency’s refusal to transfer his children’s Medi-Cal benefits.

Finally, in January of 2015, a staggering fourteen (14) months after his request, Mr. Paclik received notice of action from Alameda County Medi-Cal agency stating his November 2013 request for ICT was denied – at his own request!

This Notice applies to: (names of his children). Your eligibility to receive Medi-Cal will be discontinued the last day of 01/2015. The reason for this discontinuance is: You requested that your Medi-Cal benefits be stopped.

Having requested transfer (not discontinuance) of his Medi-Cal benefits, and weary from over a year of skullduggery, Mr. Paclik exercised his right to call for a state hearing – and was shocked again when the State Hearings Division, shortly afterward, informed him he had withdrawn that request as well.

Fortunately, after a herculean effort involving the assistance of his friend, Ronald Pierce, Mr. Paclik managed to secure a state hearing anyway. (To date, the State Hearings Division steadfastly refuses to provide any information as to who withdrew Mr. Paclik’s request, nor any substantial discovery, and consistently misrepresents the facts of the case in a manner effectively leading away from further county transparency.)

Where Mr. Paclik has been able to secure minimal discovery in that case, records of communication between Contra Costa and Alameda Counties Medi-Cal agencies during the delay are telling; revealing, at least in part, why Alameda County Medi-Cal agency falsely personated Mr. Paclik in its January, 2015 notice of action to him – the gravamen of that very hearing.

Questioner:  So you’re saying that the delay that Alameda provided in this request issue – even though there’s documentation showing that Alameda was talking with Contra Costa about the boys’ coverage, you’re saying it had nothing to do with the decision to discontinue rather than transfer, and then on top of that, make it look like Mr. Paclik requested it himself?

Alameda Rep: Just to reiterate what transpired.  The case was approved in Alameda County, and the notice of action was – indicated that it was a family of three (3).  So Mr. Charles Paclik was approved in Alameda County.  His benefits did pick up here in Alameda County.  The children’s benefits never picked up.  Because Mr. Paclik asked the worker of record at the time of application back in 2013 that he was moving, they tried to initiate the ICT – inter-county transfer – through the CalWin system which did not pick up.  But because they did try to initiate it they issued a notice of action saying the case was being terminated at the end of January 2014, at his request because he wanted the transfer.  As I previously stated, that’s a general administrative action that we take in order for us to be able to transfer the case.  So that’s what happened.  When you asked for a hearing – when the hearing took place, at that time I was involved in the case.  I noticed that the case never got transferred over.  So I thought that was the issue that needed to be resolved.  In the process, I also discovered that the children were still active in Contra Costa County and they noticed that we couldn’t transfer a case that is  active in Contra Costa County, so all we did was transfer Mr. Paclik’s case over to Fresno County, and that’s where we’re at today.

Judge:         Mr. Aguirre, if I could summarize, maybe clarify it sounds like what you’re saying is the reason the children didn’t transfer is different from the delay.  The reason the children didn’t transfer is because they were in Contra Costa, but the delay was a computer problem?  Followed by a worker problem?

Alameda Rep: That’s correct.  The actual transfer itself was because of the worker problem and the delay with the computer system not picking it up and the worker not following up on that.  That system breakdown.

Questioner:     … Just wondering why it took so long?  Why a year when there was apparently no – why did it take a year to look up on the MEDs and find this information which apparently was available when he made the request in early 2014?  What reason was there for waiting until January of the following year to effect that?  We’re just wondering why it took so long?  Is there any explanation for that from Alameda?

Alameda Rep: I think we already covered this your honor.

Judge:          He said there was a computer problem and there was some worker problems.

Questioner:     For a year?  (Followed by heavy silence.)
Mr. Paclik:      Just let it go.

This fourteen-month “oops”, wistfully supported by the hearing officer, and explained away by Alameda County as a combination computer/worker problem, remains unexplained. Furthermore, the State Hearings Division has barred Mr. Paclik from delving any further into the reasons for the delay, denying his case despite Alameda County Medi-Cal agency’s contorted admission that it falsely personated Mr. Paclik in its January, 2015 notice of action.

Against this unexplained year-long delay lies the specific modification of Mr. Paclik’s custody and visitation – as well as territorial relocation of his children’s school enrollment – during that time; these important Medi-Cal diacriticals inexplicably “tweaked” in his family court case – and his request for ICT subsequently denied along with his own Medi-Cal coverage, which, in actuality, were never transferred to Fresno County either.

In light of the fact that court FCS program facilitators often occupy the same county network as those tasked with administrating federal Medicaid services, a back-channel email from Contra Costa County Medi-Cal agency to Fresno and Alameda Counties, obtained via subpoena, revealed that Mr. Paclik’s family court case was a direct and causal issue for Medi-Cal officials refusing transfer.

Via the same “gas-lighting” as is frequently used throughout the divorce industry, Contra Costa County Medi-Cal agency’s Civil Rights Coordinator was gung ho in portraying Mr. Paclik as an abusive husband and absent father:
“He is not an applicant or recipient of aid in Contra Costa County. He is the absent parent in our case and we cannot share any confidential information about his ex-wife with him. It appears that the relationship was and is very volatile between the two parents…. he’s the absent parent so he has no legal standing in our Medi-Cal case.”Seemingly very familiar with Mr. Paclik’s family court case, Contra Costa County steadfastly balked at transferring his children’s Medi-Cal benefits, maintaining “school-based” or SMAA Medi-Cal guidelines forbade the transfer on the grounds they had unsupportedly asserted.

Whether it was a coincidence that his request for ICT was delayed just long enough for county facilitators to downward modify his custody and visitation – or no coincidence at all, the records obtained showed a clear and immediate relationship between his family law case and his Medicaid coverage under Obamacare. A relationship entirely under the discretion of county program facilitators who, pursuant to state and federal requirements, are tasked with policing themselves for fraud.

The Paclik case alone indicates that county forces in charge of administrating federal Medicaid can and will manipulate family law cases toward maintaining control over “school-based” Medi-Cal funding directly attended from custody and visitation orders.

Against Alameda County’s admission it has no explanation for the fourteen-month delay in processing his request for ICT beyond a vague reference to a “system breakdown”, the facts of Mr. Paclik’s inexplicably altered family law and Medi-Cal records together surface a far darker reality than that revealed in Rehab Racket; bringing into focus the increasing number of litigants in California decrying entrenched judicial corruption at county level, the edges and depth of which reach well beyond county limits.

While Rehab Racket lifted the rock over California’s Medi-Cal drug rehabilitation clinic network, shedding light on scurrilous Medi-Cal fraud and gross lack of county and state oversight, that investigation may have only lifted one manhole over a much larger network of subterranean Medicaid fraud.

County Mental Health Act Networks’ Administration of Federal Medicaid.

On November 2004, voters in California passed Proposition 63, the Mental Health Services Act (MHSA), which expanded and transformed California’s county mental health service systems.

Funded by imposing an additional one percent tax on individual (not corporate) taxable income in excess of one million dollars, the Department of Mental Health (DMH) asserted primacy over MHSA implementation, dictating requirements to California counties regarding Full Service Partnership (FSP) Funds – funds to provide necessary services and supports for initial populations;General System Development Funds – funds to improve services and infrastructure; and Outreach and Engagement Funding – funds for those populations that are currently receiving little or no service.

In most California counties, mental health or behavioral services are integrated with a strategic plan which is updated every three years – making county Medi-Cal TBS services part of the same network of county-contracted clinics assessing and reporting on family law litigants court-ordered to purchase their services.

This puts these county Medi-Cal collaboratives that were spawned under Proposition 63 largely in control of Medi-Cal billing, simultaneously tasking those same county networks with policing themselves for fraud. It may be of no surprise then that the Medi-Cal drug rehabilitation clinics exposed in Rehab Racket enjoyed no county oversight of their services.

In 2014, the number of Americans with health insurance grew by 9.25 million. However, a staggering 8.99 million of those folks had in fact enrolled in Medicaid, according to a report published by the Heritage Foundation. The majority of these new Medicaid enrollees are living well below the poverty line, according to a March study published by the strategic advisory firm Avalere Health.

Across America, the rising cost of Medicaid has been lamented as unsustainable without a concurrent rise in federal taxes. The Congressional Budget Office has repeatedly made clear that the main drivers of America’s debt is its unsustainable promises in Social Security benefit programs and unsustainable spending on federal health care programs – Medicare, Medicaid, health insurance subsidies under the Affordable Care Act, and others.

Medicaid expansion under the Affordable Care Act in 29 states, including California, has driven record enrollment and spending for the program in fiscal year 2015, according to a report by the Kaiser Family Foundation.

In expansion states, enrollment increased on average by 18% and total spending jumped by 17.7% – almost triple the rate in non-expansion states, where enrollment and total spending rose by 5.1% and 6.1% respectively.

In an all-new study by UC Davis researchers, it was discovered that cancer patients with Medi-Cal are generally less likely to be alive five years after diagnosis, compared with patients with other kinds of insurance. Where this is a direct byproduct of the forces between the implementation of Obamacare where it forces doctors to treat more of the poor and uninsured,

On June 28, 2012, the U.S. Supreme Court issued its landmark decision in the case of National Federation of Independent Business et al. v. Sebelius, Secretary of Health and Human Services, et al, 567 U.S. ___ (2012), 132 S.Ct 2566, challenging the constitutionality of the Affordable Care Act (ACA). Two main provisions of the 2010 health reform law were at issue.

The Court upheld the constitutionality of the ACA’s minimum essential coverage provision, known as the individual mandate, which requires most people to maintain a minimum level of health insurance coverage beginning in 2014. The most complex part of the Court’s decision concerned the ACA’s Medicaid expansion: a majority of the Court found the ACA’s Medicaid expansion unconstitutionally coercive of states because states did not have adequate notice to voluntarily consent to this change in the Medicaid program, and all of a state’s existing federal Medicaid funds potentially were at risk for non-compliance.

However, a different majority of the Court held this issue was fully remedied by limiting the Health and Human Services (HHS) Secretary’s enforcement authority, thus leaving the Medicaid expansion (and all other ACA provisions) intact in the law.

States that choose to participate in Medicaid have substantial discretion in determining whether to cover optional groups and benefits, how care is delivered, and how and what providers are paid. However, participating states must follow certain federal rules as a condition of receiving federal matching funds.

When it first established the Medicaid program, Congress gave the HHS Secretary authority to enforce state compliance with federal Medicaid program rules by withholding all or a portion of a state’s “federal matching” funds. Such a penalty can only be imposed after notice and the opportunity for a hearing and is subject to judicial review. The Secretary never has withheld a state’s entire Medicaid grant as a penalty for noncompliance with federal requirements.

Where states such as California simply pass along federal Medicaid compliance requirements to all counties, coinciding with the rise in Medi-Cal costs is the proliferation of county mental health act networks that, in the end, contract with local private, non-profit clinics in a network centered under county Mental Health Act strategy plans, provided linkage by county Health and Human Services Agencies, and geared toward Medi-Cal billing for such things as drug rehabilitation therapy and a host of other court-ordered services through divorce.

While Rehab Racket exposed an unpoliced fraudulent billing environment happening in Medi-Cal drug rehabilitation centers throughout California, that investigation arguably touched upon and even broader county network scheme siphoning Medicaid funding at an ever-increasing rate, through an ever-increasing “menu” of county-based “services”.

A problem now further expanded by passage of the Affordable Care Act, County-based federal Medicaid administration is increasingly revealed as the common link between two subjects heretofore having no shared bed; the proliferation of family court corruption, and sharply rising costs of sustaining federal Medicaid.

Where California’s family courts are increasingly outed for corruption (See, “Witch Hunt by Sean Penn; see also “Divorce Corp”; see also, Full Disclosure Network’s soon to be released “Corrupted Justice”), what begins to take shape is a possibility that, far worse than hundreds of California drug rehabilitation clinics bilking Medicaid, is the probability that counties in California and throughout America, ultimately tasked with administrating Medicaid expansion, are further using their administration for enrichment; indicating to forces interested in cutting Medicaid costs that a good place to begin would be an investigation into the “Pelletierian” divorce industry as the likely culprit.

Get the original story and updates HERE