An audit by the New Jersey Office of the State Comptroller (OSC) found that John Gore, a licensed drug and alcohol counselor, improperly billed and received over $1 million in Medicaid payments for services provided between 2016 and 2020. Gore will be required to repay the sum of $1,160,371.
Significantly, Gore billed for clinical level services provided by unlicensed professionals. Of the claims sampled by OSC, Gore failed to verify professional licenses of six clinicians who, at the time services were provided, failed to possess licenses to provide Medicaid-reimbursable services. The OSC also discovered that, during the audit period, Gore failed to obtain criminal background checks for 19 behavioral assistants prior to rendering services. Under New Jersey law, all employees providing behavioral assistance services directly to Medicaid beneficiaries are required to complete a criminal background check.
Gore’s other Medicaid program violations included failing to maintain Behavioral Assistance Training Certifications for 24 behavioral assistants, which are required to be completed within six months of the assistants’ hire date with recertifications annually thereafter. Gore was also unable to provide OSC with copies of high school diplomas or equivalents for each behavioral assistant, as required by state law, for 61 claims in the audit.
In addition to errors in documentation, Gore was found to have billed for services provided by the same servicing provider to several beneficiaries, or by different servicing providers to the same beneficiary, at the same or overlapping times. Gore also often billed for services using a higher reimbursed procedure code and/or modifier than appropriate, which resulted in overpayments.
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