A third V.I. Human Services Department employee has been arrested in connection with a Medicaid fraud scheme, V.I. Attorney General Denise George announced Sunday.
Edith Brathwaite of St. Thomas was arrested by the Medicaid Fraud Control Unit of the V.I. Justice Department for allegedly defrauding the Virgin Islands Medicaid program, George said in a press release. At the time of the alleged crime, Brathwaite was employed as an Eligibility Specialist I with the Virgin Islands Medicaid Program under the Human Services Department and received government employee health insurance benefits, the attorney general said.
The arrest arose from a joint fraud investigation by the fraud unit, the V.I. Inspector General’s Office and the federal Department of Health and Human Services Office of the Inspector General, said George. The V.I. Medicaid Fraud Control Unit is 100 percent federally funded and one of 53 such units created by Congress specifically to investigate fraud, waste, and abuse in the local Medicaid programs.
Brathwaite was arrested on a Superior Court warrant charging her with violations of the V.I. Medicaid Fraud statute, fraudulent claims upon the government, conversion of government property, embezzlement, or falsification of public records, obtaining money by false pretenses, and grand larceny, for allegedly falsifying her income information on a hospital document to a lower amount in order to qualify for presumptive Medicaid benefits of which she knew was not lawfully eligible, according to the press release.
The investigation began in February 2020 when the fraud unit received an anonymous complaint alleging that several employees of the Virgin Islands Medicaid Program were defrauding the program by fraudulently granting benefits to themselves, family members, persons living outside of the United States, and their friends, said George.
The investigation revealed that some employees were underreporting their income in order to obtain Medicaid benefits, the release stated. In some instances, the employees worked on each other’s Medicaid case and failed to report income when the income, if reported, would have disqualified the employees/applicants for benefits, according to the release.
In other cases, employees attempted several income levels until they arrived at the levels that would qualify their co-workers for benefits, the release stated. Employees enrolled undocumented persons, who are not entitled to Medicaid benefits, and continued to grant Medicaid benefits to family and friends living outside of the United States, it said. And, in other instances, employees were issued forced eligibility in order for their co-workers, whose income exceeded the Medicaid income level, to qualify for benefits.
Brathwaite is one of three employees that have been arrested thus far. The investigation revealed that all employees were covered under the Government Health Insurance and were using Medicaid to pay for their co-pay, George said.
Regarding Brathwaite, it is alleged that on Jan. 19, 2019, she went to the emergency room at the Schneider Regional Medical Center on St. Thomas for medical attention and was subsequently admitted for treatment. At some point during her stay, Brathwaite was approached by hospital Employee #1 about filling out a Hospital Presumptive Eligibility for medical benefits under the Virgin Islands Medicaid program, the release stated. Based on their conversation, Brathwaite and the hospital Employee #1 knew then that Brathwaite would not be eligible for Medicaid benefits due to her income, so she did not complete an HPE application, according to the release.
The Virgin Islands Medicaid program allows an individual who is being seen at the emergency room at a local hospital to complete a HPE application to obtain Medicaid benefits. The applicant is not required to sign the application nor to provide any verification of income, said George. Once the application process is completed, the applicant is determined to be “presumptively eligible” for benefits. Consequently, the hospital may invoice the Medicaid program for services provided to the individual and the hospital will receive payments for services provided during the 60-day period, she said. Once the HPE expires, the individual is required to submit further documentation including income to the Medicaid program to obtain benefits.
It is alleged that Brathwaite was released from the hospital on Jan. 22, 2019, and on Feb. 1, 2019, went to the hospital and requested to speak with Employee #1, according to the release. She completed an HPE application, but the employee told her that her income level would not qualify her for Medicaid benefits, so Brathwaite entered a lower amount that was false, according to the release. Based on that amount, she was qualified for benefits and the hospital was able to invoice the Virgin Islands Medicaid program for the services that Brathwaite received during her stay at SRMC, George said.
Medicaid is a multibillion-dollar joint state and federal program that provides health coverage for the economically disadvantaged. It provides essential medical care to low-income Virgin Islanders, including children. Medicaid fraud impacts the most vulnerable in our community and can place millions of dollars in federal funds to V.I. in jeopardy, said George. It costs American taxpayers an incalculable amount of money and hinders the integrity of the Medicaid program, she said.
Medicaid Fraud Control Units have long been the vehicle used to enforce health care fraud. However, in 1995, Congress enacted legislation that requires each state to have a such a unit or submit a waiver to the Secretary of the U.S. Department of Health and Human Services, according to Sunday’s release.
The Virgin Islands Medicaid Fraud Control Unit is 100 percent funded by a grant from the DHH-OIG and works cooperatively with the V.I. Human Services Department and other territorial and federal partners to prosecute fraud in the Virgin Islands Medicaid program.
“My office remains dedicated to protecting taxpayers’ dollars and pursuing potential instances of Medicaid fraud and corruption,” said George. “Through our Medicaid Fraud Control Unit, we work diligently to meet our mandate and uphold the integrity of the Virgin Islands Medicaid program and hold those accountable who would abuse the public trust.”