Sharon Y. Johnson & Associates: The Provider Supplied the Patients’ Approval

The Sharon Y. Johnson & Associates Medicaid fraud case involved false personal-care timesheets and approvals made under patients’ identities, according to the U.S. Attorney’s Office for the Eastern District of Virginia’s account of the owner’s criminal case. The business offered to supervise a recipient’s care and supply the care itself. Its owner then used patient identities to approve requests for services that had never been provided. For an aide, service facilitator or billing employee, the question is immediate: who was really on the other side of that approval?

The owner operated the Richmond-area business from 2014 through 2021. She pleaded guilty in the criminal case. The U.S. Attorney’s Office for the Eastern District of Virginia prosecuted the case and announced the outcome with the FBI Richmond Field Office.

The Service Facilitator Steered Clients to Her Own Business

Service facilitation put the business in a position to supervise a Medicaid recipient’s personal-care plan and provider. Personal-care services had a different job: helping a recipient stay at home instead of entering a nursing home or group home. The business purported to provide both Medicaid-reimbursed services.

According to the U.S. Attorney’s Office announcement describing the criminal court documents, the owner signed up numerous service-facilitation clients to receive personal care from her own company. Often, those clients did not know about the arrangement or give informed consent.

That put the oversight relationship and the income from providing care in the same hands. A client who came to the business for supervision of a care plan could become a customer of that business’s care operation without knowingly choosing it. We see the conflict in that arrangement before a timesheet even reaches billing: the person overseeing the provider also owns the provider.

We examine the facilitator assignment and the personal-care enrollment together to understand how the client reached the provider, what the client authorized and who made that choice. We want to know whether the client’s choice and the company’s enrollment record tell the same story.

Patient-Portal Impersonation Turned Consent Into a Billing Tool

According to the U.S. Attorney’s Office announcement of the criminal case, the owner and her co-conspirators created online patient-portal accounts in patients’ names, then assumed their identities to approve and route billing requests for home health care services that had not been provided.

The announcement says the owner fraudulently billed Medicaid for personal care supposedly delivered to at least 14 patients. She knowingly submitted timesheets saying particular company aides had performed services when those aides had not provided the care claimed. The false account of the work and the false account of the approval supported the same request for money.

This is the central problem in self-directed Medicaid care fraud: the recipient’s identity can appear on an approval while someone working for the provider supplies it. Here, the person seeking payment took the patient’s place in the approval process.

The paperwork could tell a complete story. An aide appeared to have worked, a patient appeared to have approved and a request moved toward payment. We see the absurdity: the business supplied the care claim and the patient’s approval of it.

An Unlicensed Group Home in the Owner’s Residence

The U.S. Attorney’s Office announcement says the owner also used her Chester residence as an unlicensed group home. It described a three-bedroom house housing up to a half-dozen Medicaid recipients alongside the owner and another employee.

The setting matters because home and community-based services pay for particular support, with the care plan identifying what the person is supposed to receive. Under the Social Security Act’s home and community-based waiver provisions, payment covers services under a written plan for people who would otherwise need institutional care. Room and board are excluded from that waiver payment.

The Separate Virginia Retirement System Scheme

The pension conduct involved another payer and another use of a resident’s identity. In its announcement of the criminal case, the U.S. Attorney’s Office said the owner submitted fraudulent documents, including a medical power of attorney, to gain control of a resident’s financial affairs.

After that resident died, the owner redirected the Virginia Retirement System pension deposit to her own bank account. The retirement system made at least eight monthly payments before confirming the death. The owner knew she was not entitled to those funds and spent them for her own purposes.

In the Medicaid scheme, the operator used patients’ identities to approve the business’s service requests. In the pension scheme, she used fraudulent documents to control a resident’s money. The common thread is control over another person’s affairs, but the payments followed separate paths: personal-care billing in one, a redirected pension deposit in the other.

What Evidence Is Needed to Prove Fraud?

For this kind of Medicaid personal-care fraud, we connect the care claimed, the person said to have delivered it, the identity used to approve it and the resulting billing request. An insider can explain who actually performed those tasks and where the electronic record gives a different impression.

Account-creation and access histories help us examine who controlled the patient account. The approval and routing history connect that account to the request for payment. We compare the portal history with the care records and the staff’s actual work. The purpose is to understand who supplied the information and who knew whether it was true.

A separate Virginia case shows why the provider’s own work records matter. Sola, Inc. paid $2,000,000 to resolve allegations of $641,396 in Medicaid overbilling for nursing units that exceeded the hours nurses actually worked, as shown by their timesheets. The comparison reached inside the group-home business: the time represented in the claims against the work recorded for the staff.

The 2012 Journal of Information Systems Applied Research study Applying Business Intelligence Concepts to Medicaid Claim Fraud Detection explored methods for identifying unusual claims in Nevada Medicaid data. Its explanation of the role of expert review is direct:

A claims analyst may see the account credited with an approval. A colleague may know that the owner created the account and operated it. We connect those views so that the apparent patient decision can be examined against the person who actually made it.

When the Existing Records Tell the False Story

False records were central to this case: the timesheets described care that had not happened, and the portal approvals carried patients’ identities. The HHS Office of Inspector General’s 2012 personal-care services portfolio makes the broader point that fraud is often proven by showing existing service documentation is false.

That is why we look past whether an approval field is filled in. We want to understand the person behind it, the service it describes and the business that used it to seek payment. Your knowledge of how the office actually worked can explain what the completed records conceal.

Can You Get Paid for Reporting Medicaid Fraud?

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

You Know Who Was Behind the Patient Account

If you saw a healthcare business use its clients’ identities to authorize its own bills, tell our Whistleblower Experts how those approvals were made. We build your strongest Medicaid whistleblower case with you around the care, the accounts and the decisions inside the business, and bring in Medicaid fraud whistleblower lawyers who understand service facilitation and personal-care billing. We stay beside you from your first account of the impersonation through the pursuit of your whistleblower case.