Moses D. deGraft-Johnson, MD, pleaded guilty Dec. 18 to 56 counts of healthcare fraud, conspiracy to commit healthcare fraud and aggravated identity theft, according to the Department of Justice.
Between late 2015 and his arrest in February of this year, Dr. deGraft-Johnson, who owned and operated the Heart and Vascular Institute of North Florida in Tallahassee, performed invasive surgical procedures on patients who didn’t need them or altered patients’ medical records to reflect procedures he didn’t perform.
As part of his plea deal, Dr. deGraft-Johnson acknowledged consistently performing two invasive diagnostic angiography procedures on hundreds of patients, whether medically necessary or not. When the patients returned for follow-up office visits, Dr. deGraft-Johnson submitted fraudulent claims to their insurance companies stating he performed atherectomies during the appointments. Using this scheme, the physician admitted he claimed to have performed more than 3,000 of these surgical procedures to clear blockages in arteries in as many as 845 of his patients’ legs.
In court documents released in February, prosecutors provided several examples of Dr. deGraft-Johnson’s fraud. In one case, he claimed to have done 14 procedures during a seven-hour period. Prosecutors said the procedures would have taken roughly 28 hours, according to The New York Times. In another example, he allegedly claimed to have performed 13 atherectomies on patients in Florida when he was traveling abroad.
Dr. deGraft-Johnson submitted false claims to insurers for the surgeries he didn’t perform and for the unnecessary procedures. As of Dec. 18, the investigation revealed he received at least $29 million through the fraud scheme.
The coronavirus pandemic and the resulting economic downturn have persuaded Americans of the importance of behavioral health care services. In the last half of August, a National Council for Behavioral Health poll (PDF) found that the gap has widened considerably between demand for mental health and addiction treatment services and the financial viability of organizations that provide them. Over half of NCBH member organizations reported that in the three months before the survey, more Americans sought their services even as these providers lost, on average, 23% of their annual revenue.
Mental health parity laws “have existed in both state and federal law for years, but insurers have used a complex determination of ‘medical necessity’ to deny care” for mental health issues and substance use disorders, Sigrid Bathen wrote in Capitol Weekly. (A recently published CHCF paper by researchers at Georgetown University’s Center on Health Insurance Reforms assessed California’s progress in enforcing the 2008 federal Mental Health Parity and Addiction Equity Act.)
The new state law requires commercial health plans and insurers outside of Medi-Cal (which is regulated by different standards) to provide full coverage for treatment of all mental health conditions and substance use disorders. This includes treatments for post-traumatic stress disorder, generalized anxiety disorder, and opioid use disorder, Sophia Bollag wrote in the Sacramento Bee. The new law also establishes specific standards for what constitutes medically necessary treatment and criteria for the use of clinical guidelines.
Creating a Certification Process for Peer Support Specialists
Under SB 803 by State Senator Jim Beall (D-San Jose), California will create a system to certify peer support specialists, define their roles, and help to scale up the Medi-Cal workforce.
In 2019, CHCF’s Lisa Aliferis visited Washington State to learn about its innovative statewide peer support program. A certified peer support specialist “identifies as having a significant life-altering mental health [or substance use] challenge and has been in recovery for at least a year,” Aliferis was told by Patti Marshall, the peer support program administrator for the Washington Health Care Authority’s behavioral health and recovery division.
Last year, California had not adopted a similar program — even though the US Centers for Medicare & Medicaid Services issued Medicaid reimbursement guidelines for peer providers in 2007. Now, research has shown that peer support for those with co-occurring mental health and substance use diagnoses prevents rehospitalizations and facilitates their ability to live in the community. “When we say [peer support] saves lives, it’s not hyperbole,” Michelle Cabrera, executive director of the County Behavioral Health Directors Association of California, told Jocelyn Wiener in an article about peer support specialists. “It really is a linchpin in moving people [with mental health and substance use disorder issues] into recovery and stabilizing them long-term.”
Expanding Community Paramedicine
Community paramedicine is a locally designed, community-based, collaborative model of care that leverages the skills of paramedics and emergency medical services (EMS) systems to take advantage of collaborations between EMS and other health care and social service providers. Among other expanded roles, community paramedics are trained to handle behavioral health needs and, depending on the locally designed program, can transport intoxicated patients to sobering centers or mental health treatment, and help frequent 911 callers to obtain behavioral health, medical, housing, and social services. All of these protocols take pressure off hospital emergency departments that traditionally have been the only permitted destinations for patients cared for by EMS agencies.
In 2015, California began testing the model of care through 13 community paramedicine pilot projects across the state. An external evaluation conducted by the Healthforce Center at UCSF found that “community paramedics are collaborating successfully with physicians, nurses, behavioral health professionals, social workers, and outreach workers to fill gaps in the health and social services safety net.”
AB 1544 by Assemblymember Mike Gipson (D-Carson) will expand the pilot projects by authorizing local EMS agencies to develop alternative destination programs.
Making Substance Use Disorder Treatment More Accessible
One-third of adults who receive county services for serious mental illnesses have a co-occurring substance or alcohol use disorder, according to Assemblymember Sharon Quirk-Silva (D-Fullerton). She authored AB 2265, which will authorize counties to use Mental Health Services Act (MHSA) funds — historically limited to mental health services — to treat Californians with co-occurring mental health and substance use disorders.