The cautionary tale of Florence Bikundi, an excluded provider


Last month, authorities arrested 25 people on federal charges related to a series of home care fraud schemes that robbed Medicaid of millions. This was the largest healthcare fraud bust in the history of the District of Columbia.

The arrestees include 51-year-old Florence Bikundi, an owner of three home care agencies who stands accused of committing a $78 million dollar Medicaid billing fraud. This began in 2007 despite Bikundi's exclusion from participation in all federal healthcare programs seven years earlier.   

That exclusion, issued against Bikundi under the name of Florence Igwacho, was based on revocation of her nursing license in Virginia. Bikundi hid her past when she applied for Medicaid provider numbers for her businesses under the name of Florence Bikundi: She didn't mention that her nursing licenses were revoked in Virginia, South Carolina and the District of Columbia, the indictment alleges.

Charges against Bikundi include multiple counts of money laundering for business practices that reportedly concealed the nature, source and location of her illegal proceeds, according to a U.S. Department of Justice announcement.

Agents seized Bikundi's $927,000 home in Bowie, Md., a 7,300-square-foot gated property featuring a pool, fountains and fake palm trees. Authorities also seized millions of dollars stashed in 46 bank accounts and towed away Bikundi's Cadillac, Mercedes Benz, Porsche, Land Rover, Range Rover and BMW.

"This investigation has revealed that Medicaid fraud in the District of Columbia is at epidemic levels," said U.S. Attorney Ronald C. Machen, Jr., in the announcement. "[A]s today's arrests, searches, and seizures demonstrate, we are aggressively fighting back to protect the U.S. taxpayer and the integrity of our federal health care programs."

News of large-scale fraud cases often contains language like this. Every big win, authorities tell us, puts would-be health insurance fraudsters on notice that crime won't be tolerated, that the government will track them down and make them pay. But Bikundi's case sends other messages that may ring louder in criminals' ears.  

First, this case shows exclusion from government programs doesn't eliminate the possibility of later crime by the ousted. And while fraud schemes are becoming more complex and sophisticated, the initial fraud in Bikundi's case--the door opener for a whole host of allegedly false claims--was simple and low-tech: She used aliases on provider applications to hide her exclusion. She got a ticket to ride because sanction screening isn't perfect. 

So the fraud remedy of exclusion--recently in the news due to questions about whether the government will use it against individuals to reduce risk in the exchanges--can serve as just a temporary setback for the determined criminal. 

Secondly, look at the dollar value of the fraud Bikundi is accused of perpetrating. How do we know this costly case was an isolated event? And will more people defraud the programs after slipping through the same cracks in the application review process?

Special investigations professionals learn early that payers must control who they allow to bill them. Bikundi's case shows how damaging errors and oversights can be here. Relatedly, legislators recently questioned the Centers for Medicare & Medicaid Services in the wake of meaningful use fraud about the agency's process for checking exclusion databases before paying providers.

And finally, forget the cliché that crime doesn't pay; healthcare fraud costs at least $80 billion annually, according to the FBI. Bikundi apparently enjoyed the trappings of wealth on the taxpayers' dime for years before getting caught.      

Florence Bikundi's case reveals embarrassing and costly fraud vulnerabilities. Let's hope the government seals them quickly. - Jane (@HealthPayer)  

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