Milestone Recovery: An Excluded Employee’s Salary in MaineCare Payments

In the Milestone Recovery fraud case, the company agreed to pay $4,519 to resolve allegations that MaineCare payments funded an excluded employee’s salary and benefits from June 2015 through July 2016. The government alleged that Milestone failed to check publicly available exclusion databases despite a disclosure in her employment application. For someone who knows the hiring file, the payroll or the billing, this case connects an employment decision to the public money that supported it.

The Disclosure Was Already in the Application

According to the Department of Justice’s account of the civil complaint, the employee had surrendered her nursing license after diverting fentanyl and oxycodone while working as a nurse at a hospital. She had subsequently been excluded from federal health care programs and MaineCare, Maine’s Medicaid program.

The complaint alleged that her Milestone employment application disclosed the circumstances of the license surrender, but the company failed to check the public exclusion databases. The allegation put the information in the employer’s hands before the employee joined.

We expect a disclosure like that to prompt more than a place in the personnel file. The government alleged that even the public database check was missed. A public database. An unchecked disclosure.

A license surrender and a program exclusion are separate events.

Federal and State Agencies Investigated

The U.S. Department of Health & Human Services, Office of Inspector General, and the Attorney General’s Office of the State of Maine investigated the case. Milestone reached its civil settlement with the United States and Maine in 2017.

MaineCare paid the employer. In its announcement, the Department of Justice said the United States funded about two-thirds of all claims submitted to the program. That puts federal money inside a state Medicaid payment and explains why the allegation reached beyond a hiring decision at a healthcare provider.

How Salary and Benefits Reach a False Claim

An excluded employee can affect a provider’s payments without personally submitting a bill. In explaining the Milestone allegations, the Department of Justice said federal health care money could not pay for an excluded person’s work, directly or through someone else. The alleged route here ran through the employer’s receipts and then the employee’s compensation.

That connection is easy to lose if a review stops at the name on a claim. The organization receives payment, while employees do the work that payment supports. A personnel decision can therefore matter inside the provider’s billing even when the employee never sends an invoice to the government.

The Office of Inspector General’s May 2013 exclusion bulletin described the payment prohibition across direct and indirect work, including payments per enrolled patient, cost reports and bundled payments. A worker’s cost can sit inside a larger payment to the organization. The salary-and-benefits allegation against Milestone makes that connection concrete.

Behavioral health work reaches a bill in different ways. An outpatient professional encounter can carry a service code tied to a practitioner and documented work. A program payment can cover work across a treatment day or a longer bundle. That difference matters when an insider knows who did the work but the claim carries the organization’s name.

We examine the actual payment arrangement alongside the worker’s role. A counselor’s encounter, a technician’s work and an administrator’s indirect work can raise different evidence questions within an exclusion review. The connection to public reimbursement is what gives the employment record its significance for a whistleblower case.

What an Exclusion Check Has to Connect

Exclusion screening connects a particular worker to a program’s payment restrictions. The Office of Inspector General’s historical bulletin recommended screening before employment and periodically afterward, with monthly screening because the list updates monthly. It also distinguished a name match from an identified person and warned against assuming that the end of a minimum exclusion period meant reinstatement.

Those distinctions matter to the insider who knows what happened after an application arrived. A hiring disclosure, a screening result and the work later paid for are different pieces of evidence. We assess how they fit together, including whose status was checked and which period the information covered.

The Milestone allegation gives that review a specific focus: the employer’s response to information already disclosed. For someone inside a provider, knowing who received that information and how it reached the people responsible for screening can explain more than the application alone. We work through that history with the reader, alongside the employment and payment records.

Another Provider’s Missed Exclusion Check

Health Care & Rehabilitation Services of Southeastern Vermont faced a similar allegation involving an excluded employee and a failure to screen. In its June 2021 resolution, the allegations concerned claims to Medicare, Medicaid and TRICARE over nearly ten years.

The parallel is the employer’s connection between staffing and reimbursement. Milestone’s case concerned MaineCare, while the Vermont allegations reached several programs. In both accounts, the excluded worker sat inside an organization seeking public payment. That is why we look beyond the person or company named on the bill to the work the payment supported.

What an Insider Can Recognize in a Small Case

The most useful knowledge may sit in the handoff between hiring, screening, payroll and billing. What information reached the employer, what the screening process did with it, and how the employee’s work connected to reimbursed services are the questions we examine. The dates matter because the employment, exclusion and payment records have to speak to the same period.

We approach that work from the whistleblower’s side. Your knowledge of how the organization operated can give the records their meaning. We work through those details with you to assess the strongest case your information supports.

A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers.

You Know How the Hiring Decision Reached Payroll

If you saw a disclosed problem go unchecked while public payments supported an employee, speak to one of our whistleblower experts about your excluded-employee case. We connect your knowledge of hiring, exclusion screening and compensation to the payment evidence, bring in behavioral health fraud whistleblower lawyers who understand excluded-provider cases, and stand beside you throughout the case.