FRIDAY, OCTOBER 18, 2019 Investigators: Eye doc’s wife inflated billing

Medicaid fraud probe spurs DHS to make system fixes

Investigators have charged a Conway optometrist’s office manager with filing inflated Medicaid claims through a state system that allowed her to “input any number she chose” without flagging abnormally high amounts, court records show.

The Department of Human Services has shut down part of its claims computer portal in the wake of the investigation, which sprung from a tip last month to the attorney general’s Medicaid fraud unit, officials said.

“We have disabled the ability for providers to claim in this way, and we’re assessing the system to determine what allowed some providers to file these specific claims in this way,” Human Services Department spokeswoman Marci Manley said Thursday.

An audit has estimated the loss to Arkansas’ Medicaid program at nearly $600,000 in this case, according to a charging affidavit signed by Rhonda Swindle, an investigator in the attorney general’s office. The Arkansas Democrat-Gazette could not determine whether other Medicaid providers are being investigated for similar reasons.

Karen R. Todd, 51, was charged with felony Medicaid fraud on Wednesday. She worked at Todd Eye Clinic, where her husband, Dr. Charles Todd, is an optometrist. A three-page investigative summary of the charge against Karen Todd did not accuse the eye doctor of wrongdoing.

Karen Todd was arrested Thursday morning and booked at the Faulkner County jail. She was released on a $30,000 bond, according to a jailhouse officer. Todd faces a Class A felony, which carries a six- to 30-year prison term and a fine of up to $15,000.

Messages left on a phone number listed for Todd were not returned.

Todd “admitted entering false information” in a state portal for so-called crossover claims, or payment requests from both Medicare and Medicaid, and “was aware she was entering fraudulent amounts and being overpaid,” Swindle wrote.

Medicare is federally funded insurance for the elderly and disabled. Medicaid, paid for by the state and federal governments, is the

insurance program primarily for low-income residents and children.

Some people have insurance from both Medicare and Medicaid. For their billing claims, health care administrators are first supposed to bill Medicare, Swindle wrote. Afterward, administrators can “cross over” to bill Medicaid to cover the co-pay and any unpaid deductible on the patient’s Medicare plan.

Co-pays are typically no more than 20% of the amount billed to Medicare, and the Medicare deductible for these claims was typically $185 at the time, Swindle wrote.

The affidavit includes a chart of six claims that show the amount Medicaid paid “far exceeds” what was billed to Medicare. For those six claims, the billed amount was $2,830, yet Medicaid paid $40,280, or more than 14-times higher.

Todd told investigators that “the Medicaid crossover portal site allowed her to input any number she chose, and the filters failed to detect the overage requests,” Swindle’s affidavit says.

A tipster on Sept. 19 accused Todd of Medicaid fraud. Investigators then examined billing data and executed a search warrant for the eye clinic’s Medicaid records Oct. 3, which is when Todd was interviewed, the affidavit says.

A spokeswoman for Attorney General Leslie Rutledge would not say whether the office is investigating other providers for similar reasons.

“The Attorney General does not disclose other potential targets of an ongoing investigation,” said the spokeswoman, Rebecca Jeffrey.

The issue with the Human Services Department portal allowed providers to manually enter Medicaid claim information, Manley said.

“We have disabled the ability to manually file a crossover claim, requiring providers to file to Medicare first — for it to then automatically crossover into our system,” Manley said. “I don’t have numbers on how many providers were using the manual filing, [but] it’s my understanding that is part of the assessment that we’re doing.”