Edgewater Systems for Balanced Living $1.25M Settlement for Fraudulently Billing Indiana Medicaid

Hammond, IN-(ENEWSPF)- United States Attorney Clifford D. Johnson announced a pre-suit settlement for $1.25 million to resolve civil claims of the United States of America and the State of Indiana against Edgewater Systems for Balanced Living, Inc., a healthcare provider in Gary, Indiana that provides mental health services, for fraudulently billing the Indiana Medicaid program.

The Indiana Medicaid program provides healthcare for low-income, often uninsured, Indiana residents who cannot otherwise afford needed medical care.  The United States and the State of Indiana jointly fund Indiana Medicaid.  The case involves Indiana Medicaid’s requirement that, before conducting and billing Indiana Medicaid for mental health counseling sessions, the provider first must draft an Individualized Integrated Care Plan (Care Plan).

The Care Plan

A physician or a Health Service Provider in Psychology, a provider with a Ph.D. Degree in Psychology must sign and approve the Care Plan.  Despite knowing of the requirement because of negative Indiana Medicaid audits during prior periods, from November 1, 2012, through and including December 31, 2017, Edgewater repeatedly billed Indiana Medicaid for mental health counseling sessions that failed to meet the requirement.

The False Claims Act prohibits an entity from knowingly submitting claims for payment to a Medicaid program that fails to comply with required billing standards. Under the False Claims Act, non-compliant billing constitutes a fraudulent claim even though a provider rendered services. Edgewater has agreed to pay the United States and the State of Indiana $1.25 million. This is for falsely billing Indiana Medicaid for the mental health counseling sessions.

The settlement came from an investigation initiated by the United States Attorney’s Office for the Northern District of Indiana. This was with assistance from the Indiana Medicaid Fraud Control Unit within the Indiana Attorney General’s Office.  Assistant United States Attorney Wayne T. Ault handled the settlement negotiations.

This is a release from the United States Department of Justice.