St. Joseph’s Hospital Health Center: Mobile Crisis Visits Without Required Professional Staff

In the St. Joseph’s Hospital Health Center fraud case, the hospital agreed to pay $3.2 million over Medicaid billing for mobile crisis visits without required professional staff. The hospital admitted that conducting those visits and then billing Medicaid was improper. For someone who knew the outreach teams or prepared their claims, the issue was concrete: the people who actually went on the visit determined whether the hospital could bill for it.

Federal and state officials announced the agreement in Syracuse, New York, on August 1, 2016.

What the Mobile Crisis Program Provided

St. Joseph’s operated a Comprehensive Psychiatric Emergency Program that evaluated and treated people experiencing an acute mental health crisis. Its mobile crisis outreach unit took initial evaluation, assessment and crisis intervention to people in Onondaga and Madison counties who were unable or unwilling to use hospital emergency-room crisis services.

The unit also provided interim crisis services after discharge from the emergency room, for patients who needed follow-up care from a mental health professional. The Justice Department’s account of the program describes a service reaching people at an immediate point of need, including people who would not come to the hospital for help.

That setting explains why the team mattered. The professional staffing requirement traveled with the service. A hospital sending people out to deliver crisis care had to meet the staffing condition for that encounter before charging Medicaid.

Two Staff Members, Including a Professional

The New York rule described in the settlement announcement required at least two of the psychiatric emergency program’s staff members whenever crisis intervention took place outside an emergency room. One had to be a member of the program’s professional staff. Payment for the program’s services depended on complying with those requirements.

The professional categories included credentialed alcohol counselors, physicians, psychiatrists, psychologists, registered professional nurses, rehabilitation counselors and social workers. That range matters to a worker reading the case: the requirement concerned the professional composition of the outreach team, with several kinds of qualified staff able to fill that role.

The government’s case put the missing professional at the center of the Medicaid claim.

What St. Joseph’s Admitted

The hospital’s admission covered both the outreach staffing and the billing that followed it. The governments alleged that St. Joseph’s knowingly submitted false claims for services delivered from January 1, 2007 through February 29, 2016 by personnel who failed to meet the staffing requirements.

The federal and state governments alleged that the hospital submitted claims without disclosing the staffing failure and accepted Medicaid payment. They said those claims misrepresented compliance with requirements central to the counseling services.

The settlement announcement then recorded the hospital’s own admission:

The Settlement Began With a Whistleblower

A whistleblower’s qui tam lawsuit under the federal and New York False Claims Acts triggered the investigation. The U.S. Attorney’s Office for the Northern District of New York, the New York State Attorney General’s Office and the U.S. Department of Health and Human Services Office of Inspector General coordinated the investigation and settlement.

The Justice Department also announced that the whistleblower would receive an award from the settlement proceeds.

Why the Staff on the Visit Mattered

A professional had to accompany the outreach team during crisis intervention outside the emergency room. That was part of the care Medicaid was paying for: someone qualified had to be there with a patient in crisis.

The requirement mattered both for people who would not come to the hospital and for those who needed follow-up after discharge. In each setting, the outreach team brought the psychiatric emergency program to the patient. The hospital admitted billing for visits without the required professional. Patients missed that professional’s care, and taxpayers paid for a service that did not meet the staffing condition.

Other Behavioral Health Claims, Different Missing Work

The St. Joseph’s staffing admission sits alongside other behavioral health cases in which the government challenged a specific part of the billed service.

In the Roanoke Comprehensive Treatment Center case, the government alleged that the center billed Virginia Medicaid for counseling represented as delivered by credentialed addiction professionals when the personnel lacked those credentials. That settlement concerned the qualifications of the people providing counseling. Its connection to St. Joseph’s is the importance of matching the actual worker to the professional service claimed.

At Oswego Hospital, the allegations concerned behavioral health claims with missing documentation, wrong dates, copied prior treatment notes and missing required time information. The hospital disclosed the problem after an internal review.

In the Community Health Care Solutions case, the government alleged Medicaid crisis-intervention claims supported by generic copied notes, often without any patient contact or service. That alleged gap goes to whether the encounter happened. In St. Joseph’s admission, the gap was the required professional’s absence from visits the hospital conducted.

Together, these cases show why the service description needs to be connected to the work underneath it: the encounter, the person providing it and the documentation supporting the bill. Each supplies a different fact that someone inside a program may know directly.

What Evidence Does a Whistleblower Need?

For a mobile crisis staffing case, the useful evidence connects the actual outreach team, its professional qualifications and the Medicaid claim for the same visit. Staffing and encounter records can show how a service happened, while the claim shows what the provider asked the government to pay for.

Our review follows the visit from the staff assignment to actual attendance and then to the Medicaid claim. An outreach worker can know who went on a visit; a biller can know which service the hospital charged to Medicaid. We bring those accounts together.

Your knowledge may concern the outreach itself or the billing that followed it. We work with you to build the case, with whistleblower lawyers who understand Medicaid behavioral health billing.

How Much of a Settlement Does a Whistleblower Get?

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

You Know Who Went on the Visit

If your mobile crisis program billed Medicaid for visits without the required professional staff, speak to one of our Whistleblower Experts about who went on those visits. We build the case with you, bring in healthcare whistleblower lawyers who know Medicaid crisis services, and stay beside you as the case moves forward.