Motion for Discovery- Janice Wrenn

XXX DISTRICT COURT
FOR THE WESTERN DISTRICT OF XXX

XXX,

Plaintiff,

vs.

XXX OFFICE OF THE ATTORNEY GENERAL, et al.,

Defendants

Case No.: CIV – XXX

MOTION FOR DISCOVERY RESPONSES

COMES NOW Plaintiff, XXX Pro-se hereby files this Motion to request this Honorable Court to order the disclosure of the Discovery Requests mentioned herein against Defendants, pursuant to Rule 6, and 26 of the Federal Rules of Civil Procedure.

BACKGROUND

During the end of XXX, the XXX Health Care Authority (OHCA) began an investigation into Plaintiff’s Wife’s business (Briggs) unbeknown to Plaintiff. The said investigation was based on complaints from disgruntled employees involving misdeeds committed by those same employees.

OHCA, instead of investigating the wrongdoers, began an investigation into Plaintiff. These investigations did not follow due process guidelines in regard Medicaid fraud. Per 42 CFR 431.107, before any action is taken against Plaintiff, Plaintiff needs to keep records and pursuant 74 XXX statute 8541, OHCA and the Oklahoma State auditor and the inspector will have the right to examine the provider’s books.

Shortly thereafter, Plaintiff’s business was terminated.

Consequential to the termination, Plaintiff transitioned her clients to Options Unlimited, a company owned by XXX. At this time, Plaintiff reasonably believed that all relevant protocols were being adhered to during the transition period. Accordingly, Plaintiff relied on XXX.

On or about the XXXX, the State of XXX, by and through unconstitutional actions of the staff of the Attorney General’s office, charged Plaintiff- a former employee of XXX to having conspired to commit several counts of Medicaid fraud. The

said charge was brought by information from XXX.

The allegations mentioned above lacked evidence.

On or about XXX, the State of XXX, by and through illegal conduct of staff of the Attorney General’s office, moved to the District Court of XXX County through Magistrate XXX, to dismiss all counts against XXX, who was the only medical provider on the date and time of the alleged offenses charged by the State. See Preliminary Hearing Transcript of XXX & AAG Testimony Da v 1 Attached Exhibit “A”.

DISCOVERY REQUESTS

In Light of the foregoing, Plaintiff makes the following requests to each Defendant:

XXX

According to 42 CFR 455.13, “the Medicaid agency must have (a) methods and criteria for identifying suspected fraud cases, (b) Methods for investigating these cases and (c) procedures, developed in cooperation with state legal authorities.” Accordingly, Plaintiff requests:

Any and all billing claims, progress notes with overpayment amounts owed for credible allegations of fraud for XXX as a provider of XXX Family and Youth Association, XXX Behavioral Health Services, Briggs Therapeutic CDC, XXX Intensive Youth Development Services and Exceptional Minds for years XXX.
any and all billing claims, progress notes with overpayment amounts owed for credible allegations of fraud for XXX as a provider of Options Unlimited from years XXX.
any and all methods of information used for investigation, administrative procedures/letters, reports sent to Secretary of State, procedural appeals of due process sent to provider, reports/claims/overpayments/adverse actions sent to Centers for Medicaid and Medicare Services, and Office of Inspector General, reported regards to all credible allegations of fraud for XXX as a provider of Briggs Family and Youth Association, XXX Behavioral Health Services, XXX Therapeutic CDC, XXX Intensive Youth Development Services and Exceptional Minds for years XXX.

According to 42 CFR 455.14 to allow a provider due process with a preliminary investigation. Plaintiff requests:

any and all preliminary investigative and audit reports used to determine credible allegations of fraud for each provider contract to include Darrick Wrenn as a provider of XXX Family and Youth Association, Briggs Behavioral Health Services, Briggs Therapeutic CDC, XXX Intensive Youth Development Services and Exceptional Minds.
any and all preliminary investigative reports and audit reports used to determine credible allegations of fraud for each provider contract for Darrick Wrenn as a provider of and Options Unlimited from years XXX.

Per 42 CFR 455. 17 (Reporting Requirements):

The agency must report the following fraud or abuse information to the appropriate Department officials at intervals prescribed in instructions:

The number of complaints of fraud and abuse made to the agency that warrant preliminary investigation.
For each case of suspected provider fraud and abuse that warrants a full investigation—

The provider’s name and number.
The source of the complaint.
The type of provider.
The nature of the complaint.
The approximate range of dollars involved; and
The legal and administrative disposition of the case, including actions taken by law enforcement officials to whom the case has been referred.

Accordingly, Plaintiff requests any and all reporting information for XXX as a provider of XXX Family and Youth Association, XXX Behavioral Health Services, XXX Therapeutic CDC, Briggs Intensive Youth Development Services and Exceptional Minds for years XXX

Plaintiff requests any and all Quality Assurance provider reports issued and served to XXXX as a provider of XXX Family and Youth Association, Briggs Behavioral Health Services, XXX Therapeutic CDC, XXX Intensive Youth Development Services and Exceptional Minds for years XXXX.
Plaintiff also requests any and all any and all Quality Assurance provider reports issued and served to XXX as a provider of Options Unlimited from years XXX.
Per 42 CFR 455.21 (a), “The agency must (1) refer all cases of suspected provider fraud to the unit.” According to termination sent to XXX on XXX, all XXX Companies were included in terminating all contracts under XXX companies and due to the credible allegations of fraud. Plaintiff is requesting any and all referrals made to the MFCU for XXX as a provider of XXX Family and Youth Association, Briggs Behavioral XXX individual contract Health Services, XXX Therapeutic CDC, XXX Intensive Youth Development Services and Exceptional Minds for years XXX.
Per 42 CFR 455.21 (a), “The agency must (1) refer all cases of suspected provider fraud to the unit.” According to termination sent to XXX on XXX, all Briggs Companies were included in terminating all contracts under XXX companies and XXX individual contract due to the credible allegations of fraud. Plaintiff is requesting any and all referrals made to the MFCU for XXX as a provider of and Options Unlimited for years XXX.
Per 42 CFR 455.23,

(a) Basis for suspension

(1) The state Medicaid agency must suspend all Medicaid payments to a provider after the agency determines there is credible allegations of fraud

(2) The state Medicaid agency may suspend payments without first notifying the provider of its intension to suspend such payments

(3) a provider may request, and must be granted, administrative review where state law so requires.

(b) Notice of Suspension …

(d) referrals to the MFCU regarding suspension.

Accordingly, Plaintiff requests any and all suspension letters, duration of suspension, suspension requests to secretary of state, payment suspension notices to continue suspension or letter of good cause to not suspend payments, termination of suspension to the MFCU to and for Darrick Wrenn as a provider of XXX Family and Youth Association, XXX Behavioral Health Services, XXX Therapeutic CDC, Briggs Intensive Youth Development Services and Exceptional Minds for years XXX.

Plaintiff requests any and all communications corresponded in regards any adverse actions, corrective plans of action for billing claims and/or credible allegations of fraud for XXX as a provider of XXX Family and Youth Association, XXX Behavioral Health Services, XXX Therapeutic CDC, XXX Intensive Youth Development Services and Exceptional Minds for years XXX.
Per 42 CFR 455. 18,

(a) Except as provided in §455.19, the agency must provide that all provider claims forms be imprinted in boldface type with the following statements, or with alternate wording that is approved by the Regional CMS Administration.

(1) ‘‘This is to certify that the foregoing information is true, accurate, and complete.’’

(2) ‘‘I understand that payment of this claim will be from Federal and State funds, and that any falsification, or concealment of a material fact, may be prosecuted under Federal and State laws.’’ (b) The statements may be printed above the claimant’s signature or, if they are printed on the reverse of the form, a reference to the statements must appear immediately preceding the claimant’s signature.

Accordingly, Plaintiff requests:

any and all provider claims with provider statements for Darrick Wrenn as a provider of XXX Family and Youth Association, XXX Behavioral Health Services, Briggs Therapeutic CDC, XXX Intensive Youth Development Services and Exceptional Minds for years XXX,
any and all provider claims with provider statements for Darrick Wrenn as a provider of and Options Unlimited XXX.

Per 42 CFR 455.20 Beneficiary Verification Procedure,

(a) The agency must have a method for verifying with beneficiaries whether services billed by providers were received.

(b) In States receiving Federal matching funds for a mechanized claims processing and information retrieval system under part 433, subpart C, of this subchapter, the agency must provide prompt written notice as required by §433.116 (e) and (f).

Accordingly, Plaintiff requests:

all proof of beneficiary verifications regarding credible allegations of fraud for Darrick Wrenn as a provider of Briggs Family and Youth Association, XXX Behavioral Health Services, Briggs Therapeutic CDC, Briggs Intensive Youth Development Services and Exceptional Minds for years XXX,
all proof of beneficiary verifications regarding credible allegations of fraud for XXX as a provider of Options Unlimited XXX.

Plaintiff requests any and all reports to HCFA recommendations for imposition of sanctions according to 42 CFR 434.67(b).

XXX

As Chief Executive Officer, Gomez’s job responsibilities requires him “To Operate and Administer the XXX State Medicaid Program” along with some of the following duties and responsibilities; Plans, coordinates, and supervises the daily operation of the organization through direct consultation and coordination with the organization’s executives and line management, Dispenses advice, guidance, direction, and authorization to carry out major plans, standards and procedures, consistent with all applicable state and federal laws, rules, regulations and policies, Meets with organization’s executives and managers to monitor and ensure that operations are being executed in accordance with the Board’s policies, Reviews operating results of the organization, compares them to approved objectives, and takes steps to ensure that appropriate measures are taken to correct unsatisfactory results, Establishes and maintains an effective system of communications throughout the organization, Represents the organization with multiple stakeholder groups, provider groups, federal and state over site agencies, the state legislature and executive branch individuals and committees;

According to XXX Health Care Authority board members. There are meetings held every quarter for board members to discuss quarterly agendas. Plaintiff requests any and all quarterly board meetings and reports to include financial and adverse actions of credible allegations of fraud for XXX as a provider for XXX Family and Youth Association, XXX Behavioral Health Association, XXX Therapeutic CDC, XXX Intensive Youth Development Services and Exceptional Minds from for years XXX.
According to XXXX Administrative Code XXX, Plaintiff requests any and all evidentiary and investigative reports from the legal division/Legal attorney counsels to include dates, violations, credible allegation of fraud, disciplinary actions, outcomes, etc. for XXX as a provider for Briggs Family and Youth Association, XXX Behavioral Health Association, XXX Therapeutic CDC, Briggs Intensive Youth Development Services and Exceptional Minds from for years XXX.
According to XXX Medicaid Fraud Control Unit investigator’s/Director, and Attorney General’s allegation that Plaintiff held a provider contract agreement after before, during and after XXX, Plaintiff requests any and all provider agreement held with Oklahoma Health Care Authority from XXX to XXX..
According to XXX Medicaid Fraud Control Unit investigator’s/Director, and Attorney General’s allegation that Plaintiff received Title 19 funds deposited into a bank account for Options Unlimited, Plaintiff is requesting for any and all proof of Title 19 funds deposited into bank accounts for Darrick Wrenn as a provider for Options Unlimited and Exceptional Minds from XXX.
According to 42 CFR 455.13, “the Medicaid agency must have (a) methods and criteria for identifying suspected fraud cases, (b) Methods for investigating these cases and (c) procedures, developed in cooperation with state legal authorities.” Plaintiff requests:

any and all billing claims, progress notes with overpayment amounts owed for credible allegations of fraud for XXX as a provider for XXX Family and Youth Association, XXX Behavioral Health Services, XXX Therapeutic CDC, XXX Intensive Youth Development Services and Exceptional Minds for years XXX,
any and all billing claims, progress notes with overpayment amounts owed for credible allegations of fraud for XXX as a provider for Options Unlimited from years XXX,
any and all methods of information used for investigation, administrative procedures/letters, reports sent to Secretary of State, procedural appeals of due process sent to provider, reports/claims/overpayments/adverse actions sent to Centers for Medicaid and Medicare Services, and Office of Inspector General, reported regards to all credible allegations of fraud for XXX as a provider for XXX Family and Youth Association, XXX Behavioral Health Services, XXX Therapeutic CDC, Briggs Intensive Youth Development Services and Exceptional Minds for years XXX.

According to 42 CFR 455.14 to allow a provider due process with a preliminary investigation. Plaintiff requests any and all preliminary investigative and audit reports used to determine credible allegations of fraud for each provider contract to include XXX as a provider for Briggs Family and Youth Association, Briggs Behavioral Health Services, Briggs Therapeutic CDC, Briggs Intensive Youth Development Services and Exceptional Minds.
According to 42 CFR 455.14, to allow a provider due process with a preliminary investigation, Plaintiff requests any and all preliminary investigative reports and audit reports used to determine credible allegations of fraud for each provider contract for Darrick Wrenn, and Options Unlimited from years XXX.
Per 42 CFR 455. 17 (Reporting Requirements):

The agency must report the following fraud or abuse information to the appropriate Department officials at intervals prescribed in instructions:

The number of complaints of fraud and abuse made to the agency that warrant preliminary investigation.
For each case of suspected provider fraud and abuse that warrants a full investigation—

The provider’s name and number.
The source of the complaint.
The type of provider.
The nature of the complaint.
The approximate range of dollars involved; and
The legal and administrative disposition of the case, including actions taken by law enforcement officials to whom the case has been referred.

Accordingly, Plaintiff requests any and all reporting information for Darrick Wrenn as a provider for XXX Family and Youth Association, Briggs Behavioral Health Services, XXX Therapeutic CDC, XXX Intensive Youth Development Services and Exceptional Minds for years XXX

Plaintiff also requests any and all Quality Assurance provider reports issued and served to XXX, XXX Family and Youth Association, XXX Behavioral Health Services, XXX Therapeutic CDC, XXX Intensive Youth Development Services and Exceptional Minds for years XXX.
Any and all Quality Assurance provider reports issued and served to XXX as a provider for Options Unlimited from years XXX.
Per 42 CFR 455.21 (a) “The agency must (1) refer all cases of suspected provider fraud to the unit.” According to termination sent to Darrick Wrenn on XXX, all XXX Companies were included in terminating all contracts under XXX companies and due to the credible allegations of fraud. Plaintiff requests any and all referrals made to the MFCU for XXX Family and Youth Association, XXX Behavioral Janice Wrenn individual contract Health Services, Briggs Therapeutic CDC, Briggs Intensive Youth Development Services and Exceptional Minds for years XXX.
According to 42 CFR 455.21 (a) “The agency must (1) refer all cases of suspected provider fraud to the unit.” According to termination sent to XXX on XXX, all XXX Companies were included in terminating all contracts under XXX companies and XXX individual contract due to the credible allegations of fraud. Plaintiff is requesting any and all referrals made to the MFCU for XXX and Options Unlimited for years XXX.
Per 42 CFR 455.23,

(a) Basis for suspension

(1) The state Medicaid agency must suspend all Medicaid payments to a provider after the agency determines there is credible allegations of fraud

(2) The state Medicaid agency may suspend payments without first notifying the provider of its intension to suspend such payments

(3) a provider may request, and must be granted, administrative review where state law so requires.

(b) Notice of Suspension …

(d) referrals to the MFCU regarding suspension.

Accordingly, Plaintiff requests any and all suspension letters, duration of suspension, suspension requests to secretary of state, payment suspension notices to continue suspension or letter of good cause to not suspend payments, termination of suspension to the MFCU to and for XXX as a provider of XXX Family and Youth Association, XXX Behavioral Health Services, XXX Therapeutic CDC, Briggs Intensive Youth Development Services and Exceptional Minds for years XXX.

Plaintiff requests any and all communications corresponded in regards any adverse actions, corrective plans of action for billing claims and/or credible allegations of fraud for XXX as a provider for XXX Family and Youth Association, XXX Behavioral Health Services, XXX Therapeutic CDC, XXX Intensive Youth Development Services and Exceptional Minds for years XXX.
Per 42 CFR 455. 18,

(1) ‘‘This is to certify that the foregoing information is true, accurate, and complete.’’

Accordingly, Plaintiff requests:

any and all provider claims with provider statements for XXX as a provider of Briggs Family and Youth Association, XXX Behavioral Health Services, XXXX Therapeutic CDC, XXX Intensive Youth Development Services and Exceptional Minds for years XXX,
any and all provider claims with provider statements for Darrick Wrenn as a provider of and Options Unlimited XXX.

Per 42 CFR 455.20 Beneficiary Verification Procedure,

(a) The agency must have a method for verifying with beneficiaries whether services billed by providers were received.

Accordingly, Plaintiff requests:

all proof of beneficiary verifications regarding credible allegations of fraud for XXX as a provider of XXX Family and Youth Association, XXX Behavioral Health Services, XXX Therapeutic CDC, XXX Intensive Youth Development Services and Exceptional Minds for years XXX,
all proof of beneficiary verifications regarding credible allegations of fraud for XXX as a provider of Options Unlimited XXX.

According to the deferred prosecution agreement signed on XXX, between XXX and Office of Attorney General et al., and According to investigator statement made in the probable cause of affidavit naming XXX as the co-conspirator of Options Unlimited with XXX and XXX, Plaintiff requests proof of payments made on claims to XXX Health Care Authority, and any and all claims involved with restitution amount of $154,600.75 paid to the Office of Attorney General in lieu of MFCU Unit of Claims from XXX filing of charges count 1 through 3. Claims information to include Provider name, provider number, type of service, treatment, recipient name and dates per service claim.

XXX.

Plaintiff requests any and all preliminary investigation reports and full investigation reports received from the Medicaid Fraud Control Unit for XXX and provider contracts from the XXX Health Care Authority in the name of Darrick Wrenn.
Plaintiff requests any and all termination letter for provider contracts in the name of XXX and provider contracts from the XXX Health Care Authority in the name of XXX.
Plaintiff requests any and all claims of overpayment amounts referenced by the Medicaid Fraud Control Unit related to credible allegation of fraud charges 1 and 3.
Plaintiff requests any and all conclusory evidence used prior to filing of charges 1 and 3.
Federal law defines a “credible allegation of fraud” as an allegation, which has been verified by the State, from any source. According to 42 CFR 455.2, the source of these allegations may include, but are not limited to; fraud hotline complaints, claims data mining, patterns identified through provider audits, civil false claims cases, and law enforcement investigations. Allegations are considered credible when they have indicia of reliability and the State Medicaid Agency has reviewed all allegations, facts and evidence carefully and acts judiciously on a case-by-case basis. It follows; Plaintiff requests any and all evidence used to substantiate credible allegations of fraud for XXX Family and Youth Services, XXX Behavioral Health Services, XXX Therapeutic CDC, XXX Intensive Youth Developments Services, Exceptional Minds and Options Unlimited from XXX. (XXX- for XXX).
According to 455.101, Plaintiff requests any and all exclusions or suspension from the US Department of Health and Human Services/Office of Inspector General for XXX Family and Youth Association, XXX Behavioral Health Services, XXX Therapeutic CDC, XXX Intensive Youth Developments Services, Exceptional Minds and Options Unlimited from XXX and present. (XXXX- for XXX).
Plaintiff requests any and all documentation and agreements that show XXX interest as a provider from years XXX for XXX Family and Youth Services, XXX Behavioral Health Services, XXX Therapeutic CDC, XXX Intensive Youth Developments Services, Exceptional Minds and Options Unlimited.
According to 455.232(b), Plaintiff requests any and all auditing of claims for payments and administering of service rendered by XXX as a provider for XXX Family and Youth Association, XXX Behavioral Health Services, XXX Therapeutic CDC, XXX Intensive Youth Developments Services, Exceptional Minds and Options Unlimited from XXX and present. (XXX- for XXX).
According to 455.232 (c), Plaintiff requests any and all overpayments being made. According to the deferred prosecution agreement signed on XXX, between XXX and Office of Attorney General et al. And According to investigator statement made in the probable cause of affidavit naming XXX as the co-conspirator of Options Unlimited with XXX and XXX Plaintiff is requesting proof of payments made on claims to XXXX Health Care Authority, and any and all claims involved with restitution amount of $154,600.75 paid to the Office of Attorney General in lieu of MFCU Unit of Claims from XXX filing of charges count 1 through 3. Claims information to include Provider name, provider number, type of service, treatment, recipient name and dates per service claim.

MYKEL FRY (DIRECTOR & ATTORNEY FOR MFCU), THOMAS SIEMS (INVESTIGATOR FOR MFCU)

According to 42 CFR 455.23, the agency or prosecuting authorities determine that there is insufficient evidence of fraud by the provider or legal proceedings related to the providers alleged fraud are completed. Document should be in writing and part of the MFCU file. Plaintiff requests:

any and all proof of payment suspension notice or letter for XXX as a provider for Briggs Family and Youth Association, XXX Behavioral Health Services, XXX Therapeutic CDC, and XXX Intensive Youth Development Services, Exceptional Minds claims for years XXX pertaining to charges filed for XXX counts 1 and 3.
any and all proof of payment suspension notice or letter for XXX as a provider for Options Unlimited Claims for years XXX pertaining to charges filed for XXX.
any and all proof of payment suspension notice or letter filed with the secretary of state for XXX as a provider for XXX Family and Youth Association, XXX Behavioral Health Services, XXX Therapeutic CDC, and XXX Intensive Youth Development Services, Exceptional Minds claims for years XXX pertaining to charges filed for XXX.
any and all proof of payment suspension notice or letter filed with the secretary of state for Options Unlimited Claims for years XXX pertaining to charges filed for XXX.

According to 455.13 (Methods for identification, investigation, and referral used), Plaintiff requests:

any and all evidentiary reports involving the investigation of credible allegations of fraud from the MFCU unit to include the following: beginning and ending dates of all investigations for XXX Family and Youth Association, XXX Behavioral Health Services, XXX Therapeutic CDC, and XXX Intensive Youth Development Services, Exceptional Minds pertaining to charges filed for Darrick Wrenn 1 through 3 from XXX.
any and all evidentiary and investigation reports involving the investigation of credible allegations of fraud from the MFCU unit to include the following: beginning and ending dates of all investigations for Options Unlimited pertaining to charges filed for XXXX.

Plaintiff requests any and all Office of Inspector General overpayment reports, Investigation reports, Adverse Action reports and annual reports from XXXX.
Plaintiff requests Any and all claims related to credible allegations of fraud for Darrick Wrenn as a provide for Options Unlimited from XXXX.
According to 42 CFR 455.14, a preliminary investigation is conducted by the state agency and a referral is included to warrant a full investigation according to 42 CFR 455.15. Plaintiff requests:

any and all findings from the preliminary investigation from the state agency (XXXX Health Care Authority) that warrant the full investigation for XXX as a provider for XXX Family and Youth Association, XXX Behavioral Health Services, XXX Therapeutic CDC, and Briggs Intensive Youth Development Services, Exceptional Minds from XXX.
any and all finding from the preliminary investigation from the state agency (Oklahoma Health Care Authority) that warrant the full investigation for XXX as a provider for Options Unlimited from XXX.

According to MFCU standard #8 (Cooperation with Federal Authorities). Plaintiff requests any and all MFCU investigations and all persons involved and their positions/credentials with the MFCU unit investigating on XXX, Companies and Options Unlimited for years XXX.
According to 42 CFR 455.16, MFCU will carry all resolution information from investigation. Plaintiff requests any and all resolutions of full investigation reports with findings and dates of the conclusion for XXX, XXX Family and Youth Association, XXX Behavioral Health Services, XXX Therapeutic CDC, and Briggs Intensive Youth Development Services, Exceptional Minds, and Options Unlimited.
According to 42 CFR 455.17, MFCU will carry evidence of the case. Plaintiff requests any and all evidence resolved to include recovery of payments, warning letters, and other documents received from XXX Health Care Authority.
Plaintiff requests any and all feedback and communications with XXX Health Care Authority and secretary of state to include quarterly certifications pertaining to suspension of payments for XXX Family and Youth Association, XXX Behavioral Health Services, XXX Therapeutic CDC, and XXX Intensive Youth Development Services, Exceptional Minds for years XXX.
Plaintiff requests any and all feedback and communications with XXX Health Care Authority and secretary of state to include quarterly certifications pertaining to suspension of payments for XXX and Options Unlimited for years XXX.
According to MFCU Performance Standard #7 of MFCU policies and procedures, plaintiff requests:

any and all opening and closing of all investigations and progress of all cases, interview summaries, relevant facts and length of time, and reviews that are conducted by supervisors periodically, consistent with MFCU policies and procedures, and are noted in the case file. regarding Darrick Wrenn, Briggs Family and Youth Association, Briggs Behavioral Health Services, Briggs Therapeutic CDC, and Briggs Intensive Youth Development Services, Exceptional Minds, and Options Unlimited for years 2012-2021
any and all opening and closing of all investigations and progress of all cases, interview summaries, relevant facts and length of time, and reviews that are conducted by supervisors periodically, consistent with MFCU policies and procedures, and are noted in the case file. regarding XXX and Options Unlimited for years XXX.

According to Title IV of the Health Care Quality Improvement Act of 1986 (HCQIA), public law 99-660, and Section 1921 and 1128E of the Social Security Act, MFCU is to report any adverse actions within 30 days of the investigation. In that light, Plaintiff requests:

any and all NPDB reports filed for any adverse actions for XXX, XXX Family and Youth Association, XXX Behavioral Health Services, XXX Therapeutic CDC, and XXX Intensive Youth Development Services, Exceptional Minds, and Options Unlimited.
any and all NPDB reports filed for any adverse actions for XXX and Options Unlimited.

According to 42 CFR Section 455.21, to refer instances of suspected fraud, provider abuse referrals are referenced in the regulations only in 42 CFR section 455.15. Plaintiff requests all referrals in reference to the credible allegations of fraud for XXX, XXX Family and Youth Association, XXX Behavioral Health Services, Briggs Therapeutic CDC, and XXX Intensive Youth Development Services, Exceptional Minds, and Options Unlimited for years XXX. A MFCU referral must contain the minimum criteria set forth in the “Acceptable Referrals from States to MFCUs Performance Standard” released by CMS in XXX in conjunction with this Best Practices document. The following information should be included to assist in facilitating the MFCU’s evaluation of a case:

Subject (name, Medicaid provider ID, address, provider type)
Source/origin of complaint
Date reported to State: This is the date on which the PIU received the information that the provider being referred might be engaged in illegal behavior. If the PIU developed the information on its own, then it should provide the date when the PIU initiated an investigation of the provider. In the event a PIU ranking report or other data analysis revealed the provider, the date of the report should be used.
Description of suspected intentional misconduct, with specific details including: The category of service. Factual explanation of the allegation: The PIU should provide as much detail as possible concerning the names, positions, and contact information (if available) of all relevant persons; a complete description of the alleged scheme as it is understood by the PIU, including, when possible, one or more examples of specific claims that are believed to be fraudulent; the manner in which the PIU came to learn of the conduct; and the actions taken by the PIU to investigate the allegations. Specific Medicaid statutes, rules, regulations, or policies violated: This information should include an explanation of why the conduct of the provider or individual violates the statutes, rules, regulations, or policies. Date(s) of conduct: When exact dates are unknown, the PIU should provide its best estimate.
Amount paid to the provider for the last three years or during the period of the alleged misconduct, whichever is greater: This information should also include a claims detail with fields such as TCN, date of service, provider ID, ID, diagnosis code, procedure code, and modifier.
All communications between the State Medicaid agency and the provider concerning the conduct at issue: This section should include any communications that began with a question from the provider, provider enrollment documentation, and any education given to the provider as a result of past problems; as well as advisory bulletins, policy updates, or any other general communication to the provider community regarding the questionable behavior. Letters, emails, and phone logs are all sources of communication.
Contact information for State Medicaid agency staff persons with practical knowledge of the workings of the relevant program.

According to the deferred prosecution agreement signed on XXX, between XXX and Office of Attorney General et al., and according to investigator statement made in the probable cause of affidavit naming XXX as the co-conspirator of Options Unlimited with XXX and XXX, Plaintiff requests:

proof of payments made on claims, and any and all claims involved with restitution amount of $154,600.75 paid to the Office of Attorney General in lieu of MFCU Unit of Claims from filing of charges count 1 through 3. Claims information to include Provider name, provider number, type of service, treatment, recipient name and dates per service claim.
proof of payments reported to Office of Inspector General and/or Centers of Medicare and Medicaid Services with any and all claims involved with restitution amount of $154,600.75 paid to the Office of Attorney General in lieu of MFCU Unit of Claims from filing of charges count 1 through 3. Claims information to include Provider name, provider number, type of service, treatment, recipient name and dates per service claim.

According to the U.S Department of Health and Human Services, as part of a Medicaid investigation, the individual’s that participate in an active investigation must receive approval of the Inspector General of the relevant federal agency to investigate fraud in other federally funded health care programs, especially if the case is primarily related to Medicaid. Plaintiff requests any and all Office of Investigator reports, or adverse actions reports from: The National Association of Medicaid Fraud Control Units (NAMFCU), Federal Bureau of Investigation and Centers for Medicare and Medicaid Service for years XXX.

NICOLE NANTOIS

According to 42 CFR 455.13, “the Medicaid agency must have (a) methods and criteria for identifying suspected fraud cases, (b) Methods for investigating these cases and (c) procedures, developed in cooperation with state legal authorities.” Accordingly, Plaintiff requests:

any and all billing claims, progress notes with overpayment amounts owed for credible allegations of fraud for XXX as a provider of Briggs Family and Youth Association, XXX Behavioral Health Services, XXX Therapeutic CDC, Briggs Intensive Youth Development Services and Exceptional Minds for years XXX.
any and all billing claims, progress notes with overpayment amounts owed for credible allegations of fraud for Darrick Wrenn as a provider of Options Unlimited from years XXX.
any and all methods of information used for investigation, administrative procedures/letters, reports sent to Secretary of State, procedural appeals of due process sent to provider, reports/claims/overpayments/adverse actions sent to Centers for Medicaid and Medicare Services, and Office of Inspector General, reported regards to all credible allegations of fraud for XXX as a provider of XXX Family and Youth Association, XXX Behavioral Health Services, XXX Therapeutic CDC, Briggs Intensive Youth Development Services and Exceptional Minds for years XXX.

According to 42 CFR 455.14 to allow a provider due process with a preliminary investigation. Plaintiff requests:

any and all preliminary investigative and audit reports used to determine credible allegations of fraud for each provider contract to include XXX as a provider of XXX Family and Youth Association, XXX Behavioral Health Services, XXX Therapeutic CDC, Briggs Intensive Youth Development Services and Exceptional Minds.
any and all preliminary investigative reports and audit reports used to determine credible allegations of fraud for each provider contract for Darrick Wrenn as a provider of and Options Unlimited from years XXX.

Per 42 CFR 455. 17 (Reporting Requirements):

The agency must report the following fraud or abuse information to the appropriate Department officials at intervals prescribed in instructions:

The number of complaints of fraud and abuse made to the agency that warrant preliminary investigation.
For each case of suspected provider fraud and abuse that warrants a full investigation—

The provider’s name and number.
The source of the complaint.
The type of provider.
The nature of the complaint.
The approximate range of dollars involved; and
The legal and administrative disposition of the case, including actions taken by law enforcement officials to whom the case has been referred.

Accordingly, Plaintiff requests any and all reporting information for XXX as a provider of XXX Family and Youth Association, XXX Behavioral Health Services, XXX Therapeutic CDC,XXX Intensive Youth Development Services and Exceptional Minds for years XXX.

Plaintiff requests any and all Quality Assurance provider reports issued and served to XXX as a provider of XXX Family and Youth Association, XXX Behavioral Health Services, XXX Therapeutic CDC, XXX Intensive Youth Development Services and Exceptional Minds for years XXX.
Plaintiff also requests any and all any and all Quality Assurance provider reports issued and served to Darrick Wrenn as a provider of Options Unlimited from years XXX.
Per 42 CFR 455.21 (a), “The agency must (1) refer all cases of suspected provider fraud to the unit.” According to termination sent to XXX on XXX, all XXX Companies were included in terminating all contracts under XXX companies and due to the credible allegations of fraud. Plaintiff is requesting any and all referrals made to the MFCU for XXX as a provider of XXXX Family and Youth Association, XXX Behavioral XXX individual contract Health Services, XXX Therapeutic CDC, XXX Intensive Youth Development Services and Exceptional Minds for years XXX.
Per 42 CFR 455.21 (a), “The agency must (1) refer all cases of suspected provider fraud to the unit.” According to termination sent to XXX on XXX, all Briggs Companies were included in terminating all contracts under Briggs companies and XXX individual contract due to the credible allegations of fraud. Plaintiff is requesting any and all referrals made to the MFCU for XXXX as a provider of and Options Unlimited for years XXX.
Per 42 CFR 455.23,

(a) Basis for suspension

(1) The state Medicaid agency must suspend all Medicaid payments to a provider after the agency determines there is credible allegations of fraud

(2) The state Medicaid agency may suspend payments without first notifying the provider of its intension to suspend such payments

(3) a provider may request, and must be granted, administrative review where state law so requires.

(b) Notice of Suspension …

(d) referrals to the MFCU regarding suspension.

Accordingly, Plaintiff requests any and all suspension letters, duration of suspension, suspension requests to secretary of state, payment suspension notices to continue suspension or letter of good cause to not suspend payments, termination of suspension to the MFCU to and for XXX as a provider of XXX Family and Youth Association, XXX Behavioral Health Services, XXX Therapeutic CDC, XXX Intensive Youth Development Services and Exceptional Minds for years XXX.

Plaintiff requests any and all communications corresponded in regards any adverse actions, corrective plans of action for billing claims and/or credible allegations of fraud for XXXX as a provider of XXX Family and Youth Association, XXX Behavioral Health Services, XXX Therapeutic CDC,XXX Intensive Youth Development Services and Exceptional Minds for years XXX.

Per 42 CFR 455. 18,

(1) ‘‘This is to certify that the foregoing information is true, accurate, and complete.’’

Accordingly, Plaintiff requests:

any and all provider claims with provider statements for XXX as a provider of XXX Family and Youth Association, XXX Behavioral Health Services ,XXX Therapeutic CDC, XXX Intensive Youth Development Services and Exceptional Minds for years XXX,
any and all provider claims with provider statements for XXX as a provider of and Options Unlimited XXX.

Per 42 CFR 455.20 Beneficiary Verification Procedure,

(a) The agency must have a method for verifying with beneficiaries whether services billed by providers were received.

Accordingly, Plaintiff requests:

all proof of beneficiary verifications regarding credible allegations of fraud for XXX as a provider of Briggs Family and Youth Association, Briggs Behavioral Health Services, XXX Therapeutic CDC, XXX Intensive Youth Development Services and Exceptional Minds for years XXX
all proof of beneficiary verifications regarding credible allegations of fraud for XXX as a provider of Options Unlimited XXX.

WHEREFORE, these premises considered, Plaintiff humbly moves this Court for an order of the Disclosure of the aforesaid Requests.

Respectfully submitted,

DATED:

CERTIFICATE OF MAILING

I, XXX, certified on this day of .XXX, I deposited a true copy of the above to the defendant by placing the documents with prepaid postage in the XXX mailbox address to each person.

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Motion for Discovery- Janice Wrenn

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