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AG charges former therapist for Raton provider with Medicaid fraud

Attorney General Hector Balderas’ office has charged a former therapist for a Raton behavioral health provider with Medicaid fraud for allegedly providing false billing information to the agency.

The criminal complaint, filed two weeks ago in Colfax County Magistrate Court, was disclosed today by the Human Services Department at a hearing before the Legislative Finance Committee.

Neither the AG nor the Human Services Department had announced it earlier.

According to the complaint and a statement of probable cause, Debra Vega-Cowan, who worked for Service Organization for Youth in Raton, submitted billing documents to SOY that were false, or indicated services that were not provided, from August 2010 to December 2012. She was charged with four counts of Medicaid fraud, each a fourth-degree felony.

Balderas said the charges were filed as a result of a criminal investigation conducted by his office’s Medicaid Fraud and Elder Abuse Division.

According to James Hallinan, the AG’s spokesman, the information that led to the investigation was provided as part of HSD’s referral of SOY in 2013. The agency referred SOY and 14 others to the AG to investigate for possible fraud after it said an audit by Boston-based Public Consulting Group showed overbilling.

Although the allegations involving Vega-Cowan were part of HSD’s referral, they were not included in the PCG audit, Hallinan said.

The AG’s investigation into SOY itself has been finished and should be announced soon, the spokesman also said.

HSD spokesman Matt Kennicott said the agency is glad Balderas took the action and said the charges “send a clear message that fraud and abuse will not be tolerated in New Mexico’s behavioral health system.”

At the Legislative Finance Committee meeting, lawmakers troubled that fragile clients are facing yet another shift to new providers in southern New Mexico pressed HSD officials about how behavioral health care will be delivered.

The second of two Arizona companies brought in by HSD in 2013 to replace local providers is leaving New Mexico. La Frontera will be gone in a little over two months, and Turquoise Health and Wellness has left.

“My concern is that we have our very vulnerable population that has experienced not one, but two, transitions,” said Rep. Stephanie Garcia Richard, D-Los Alamos.

Other legislators questioned HSD’s decision to use Santa Fe-based Presbyterian Medical Services to replace the two Arizona providers at some sites.

PMS was among the 15 New Mexico providers HSD referred to the attorney general.

The company denied overbilling, paid HSD $4 million in a settlement agreement a few months later, and continued to provide behavioral health services. The AG’s investigation into PMS is pending, although CEO Steve Hansen told the Journal this week that he did not expect it to turn up any problems.

HSD Secretary Brent Earnest said PMS, which has a network of about 50 clinics providing medical, dental and behavioral health services, is “a really good partner moving forward.”

But legislators suggested the agency’s decision undermines its rationale for shaking up the system two year ago, after it said an audit had shown $36 million in overpayments, widespread mismanagement and possible fraud.

“It really does bring into question the credibility of all the allegations that were brought forward” in the 2013 shake-up, said Sen. Howie Morales, D-Silver City.

Sen. William Burt, R-Alamogordo, told Earnest he was concerned PMS “doesn’t have a clean slate” and should be closely scrutinized in its expanded role.

“For the folks using these services, we don’t want to interrupt them any more than we already have,” Burt said.