IAM Healthcare: How Operators Turned Offers of Care Into False Bills

Teletherapy fraud involving IAM Healthcare generated approximately $534,438 in Medicare claims for mental-health services never provided, according to the Justice Department’s account of the criminal trial. Offers of counseling, electronic health records conversion and free food supplied beneficiary information. The people whose identities made the claims possible never received the care the company billed Medicare for.

Integrated Alliance for Managed Healthcare, PLLC, known as IAM Healthcare, engaged a licensed clinical social worker to provide mental-health services primarily through telehealth. The Justice Department’s earlier account of the indictment describes that arrangement. A federal jury convicted the operator, who was from Raleigh. The social worker, from Greensboro, pleaded guilty to conspiring to defraud Medicare.

For someone inside outreach, a facility, a clinical practice or billing, the important connection runs from the offer to the beneficiary’s information and then to the claim. The criminal information also alleges that the social worker reused beneficiary information to bill under Marvor Healthcare.

Teletherapy Offers Opened the Door to Medicare Information

The criminal trial account describes several ways the operator’s company obtained Medicare information: offers to assisted-living homes, food offered at churches and cold calls offering telehealth services. The operation used offers of help to obtain information from elderly, disabled and low-income people, then billed their public health care program for therapy they never received.

Electronic Health Records and Assisted-Living Homes

The company offered electronic health records conversion and teletherapy counseling to assisted-living homes for elderly and disabled residents. Those offers connected a business service for the facility with a proposed clinical service for its residents.

An offer to help a facility with records can put beneficiary information into a company’s hands before the promised care occurs. Here, the Justice Department’s trial account identifies the conversion and counseling offers as a way of obtaining the information used in the scheme.

For a facility employee, the entry point might have looked like a records project. For a clinician, it might have looked like a new patient list.

Food Offers and Cold Calls

At churches in Bladen County, the company offered free food in exchange for Medicare information from low-income elderly parishioners. The trial account also describes cold calls offering telehealth services.

The earlier indictment account identifies IAM Healthcare Foundation as the entity through which the operator offered food for beneficiary information. The Medicare billing described in the same announcement went through IAM Healthcare.

Food was the offer. Mental-health treatment was the bill. The company obtained Medicare information through one and requested payment for the other.

Claims for Mental-Health Services That Never Happened

Witness testimony and evidence at the criminal trial described more than 5,000 Medicare claims involving approximately 145 beneficiaries. The claimed mental-health services covered October 2018 through February 2020. The Justice Department said the beneficiaries never received those services.

The criminal information against the social worker, the document setting out the government’s charges, explains the billing pathway. Medicare Part B covers outpatient mental-health services. The filing describes claims identifying the provider and patient records that must verify the service described on the claim. For a practitioner associated with a group, it describes the individual provider number as part of the claim. That puts the professional’s identity alongside the group’s billing, another connection an employee may recognize from the work.

The government’s trial account puts the falsehood in the bill: it claimed care the beneficiary never received. The promise of counseling did the work of attracting information. The claim did the work of requesting payment. Between them should have been the care.

The Alleged Reuse of Beneficiaries Under Marvor

The criminal information describes claims under IAM Healthcare and later claims under Marvor Healthcare. It alleges that the later billing reused beneficiaries from the IAM Healthcare scheme.

The information then alleged that the social worker submitted claims using the name Marvor Healthcare between January and June 2020. Those claims involved approximately 24 beneficiaries previously billed under the IAM Healthcare scheme. Medicare paid Marvor approximately $37,209, according to the filing.

The overlap is the point. The same beneficiary information appeared in claims under a different entity name. Looking only at one company’s billing would leave out the later use alleged in the information.

For an insider who recognizes the patients, the link is visible even when the business name changes. A beneficiary list, a provider’s identity and a set of claimed service dates can connect billing that otherwise looks like separate operations.

What Evidence Is Needed to Prove Fraud?

It takes connecting the patient contact, the clinical work and the claims, and that is the work our whistleblower experts do with you. In this case, the connection runs from the offers that obtained Medicare information to the health care services billed under different business names.

An outreach employee may know what callers offered and what information they requested. Someone working on records conversion may know how a facility’s information entered the system. A clinician may know which patients received care, while a billing employee may see the provider identity, service dates and payments.

Aptihealth and Billing for Absent Care

Aptihealth‘s civil settlement admissions offer a related example: Medicare and Medicaid were billed for appointments patients missed. The same gap between billing and care appears in the IAM Healthcare trial account, which describes how beneficiary information obtained through outreach became claims for care never delivered. For a whistleblower, knowing what the patient actually received is what gives the billing records their meaning.

A Whistleblower’s Knowledge Can Connect the Claims

If your work connects outreach or patient records to false Medicare billing, our whistleblower experts can assess that connection with you. A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers.

You Know Where the Patient Information Came From

If you saw a records project, counseling offer or food program feed Medicare billing for care that never happened, your inside knowledge can connect the outreach to the claims. We work alongside you throughout the case and bring in healthcare fraud whistleblower lawyers who understand mental-health billing and beneficiary identity schemes. Speak with our whistleblower experts about building your strongest case from what you know.