Addiction Recovery Care and Affiliates Agree to Pay $16.2 Million Civil Judgment to Resolve Medicaid Fraud Allegations

ASHLAND, Ky. - Addiction Recovery Care, LLC ("ARC"), and its affiliates Pioneer Health Group, LLC and Science Hill Family Care, LLC, have agreed to a civil judgment of $16,205,774.05 in favor of the United States to resolve allegations that they defrauded the Kentucky Medicaid program. ARC, headquartered in Louisa, Kentucky, operates residential and outpatient drug rehabilitation facilities throughout the state. Along with its affiliates, ARC offers behavioral healthcare and medical healthcare services to patients at their rehabilitation facilities.

The judgment, announced today by the U.S. Attorney's Office and the Office of the Kentucky Attorney General, is part of a civil settlement resolving allegations that ARC and its affiliates violated the False Claims Act, a federal statute that prohibits the submission of false claims for payment to Government programs, including the Medicaid program.

In April 2023, current and former employees of ARC filed a qui tam complaint alleging that ARC defrauded the Kentucky Medicaid program by submitting fraudulent claims for payment for behavioral health services provided in their drug rehabilitation programs. Under the qui tam provisions of the False Claims Act, a citizen can file a civil action on behalf of the United States to bring allegations of fraud to the Government's attention. The United States thereafter opened a civil investigation into whether ARC violated the False Claims Act. During the Government's investigation, ARC self-disclosed to the Government that it should not have billed for some of its services, including services identified by the whistleblowers in the qui tam complaint.

According to the settlement agreement, the Government alleged that ARC falsely represented the qualifications of some of their clinicians on claims to Kentucky Medicaid in order to receive higher reimbursements. From January 2018 to March 2024, some of ARC's behavioral health services, such as psychotherapy, psychiatric evaluations, and mental health assessments, allegedly were provided by lower-level healthcare workers but billed as if ARC's employees had higher-level licenses. Similarly, from July 2019 to mid-June 2021, the Government alleged that ARC falsely represented that it provided individual group therapy sessions, which Kentucky paid at a higher rate, when ARC in fact provided less expensive group therapy sessions. These alleged overstatements of provider qualifications and individualized care, which are commonly referred to as "upcoding," are not allowed by federal health insurance programs and caused ARC and its affiliates to receive higher payments to which they were not entitled.

In addition to ARC's purported upcoding practices, the Government alleged that, from January 2019 to December 2024, ARC's affiliates billed duplicate office visits to Kentucky Medicaid and billed for office visits that were already reimbursed under an inclusive per diem rate. One of ARC's affiliates also allegedly charged for care management services that did not meet Kentucky Medicaid's coverage requirements, including services performed by ARC employees who lacked the necessary credentials.

The civil judgment and settlement agreement resolve the qui tam case captioned United States ex rel. Rikki Pope, et al. v. Addiction Recovery Care, LLC, Case No. 0:23-cv-51-DLB, which was recently unsealed by the Court. The amount of the judgment, which will be paid over several years, was negotiated and reduced due to Defendants' financial condition and prospects for ongoing operations. As part of this resolution, the individuals who filed the qui tam complaint are eligible to receive a portion of the settlement proceeds.

This matter was investigated by the Affirmative Civil Enforcement section of the U.S. Attorney's Office, with assistance from the U.S. Department for Health and Human Services, Office of Inspector General, the Kentucky Office of Attorney General, Office of Medicaid Fraud and Abuse Control, and the Federal Bureau of Investigation. Assistant U.S. Attorney Meghan Stubblebine and former Assistant U.S. Attorney Katie Sheridan represented the United States.

The claims resolved by the settlement are allegations only; there has been no determination of liability.

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