As part of its oversight of the New Jersey Medicaid program (Medicaid), the New Jersey Office of the State Comptroller, Medicaid Fraud Division (OSC) conducted an audit of Medicaid claims submitted by and paid to Sokkyun Yi (Yi), a licensed clinical social worker, for the period from September 21, 2016 through March 2, 2020 (audit period).

OSC’s audit sought to determine whether Yi billed for intensive in-community mental health rehabilitation and behavioral assistance services in accordance with applicable state regulations. OSC randomly selected 37 service dates, representing 963 claims, and determined that 33 of the 37 sampled service dates, or 518 of the 963 claims (54 percent), failed to comply with state regulations. The 518 failed claims contained 704 total exceptions, as some claims failed for multiple reasons. OSC extrapolated the error dollars ($75,423) to the total population from which the sample was drawn, and calculated that Yi received an overpayment of at least $1,795,277.^[1]

OSC’s audit found numerous documentation deficiencies-- for example, forms that were missing pages, forms that contained inaccurate or conflicting information, and forms that were missing required signatures. In several instances, Yi billed for services that could not be substantiated, or “upcoded” claims-- billing for a higher-level, higher-cost service than what was actually provided. OSC also found several instances in which Yi improperly billed for travel time or billed for overlapping services (services performed by the same provider at the same time for different beneficiaries). OSC also found several instances in which Yi did not document services with a progress note. Lastly, OSC found that Yi failed to maintain documentation showing that he performed the necessary safety checks for those he employed. In several instances, he did not have documentation showing that the behavioral assistants (BA) he employed had required certifications, education, proof of age, criminal background checks and/or valid driver’s licenses.

OSC seeks a total recovery from Yi of $1,795,277 and makes several recommendations to Yi for correcting the deficiencies identified in this report. Taken as a whole, OSC’s findings present a troubling pattern of Yi failing to meet core regulatory requirements in a manner that not only led to him receiving overpayments, but also increased the risk that he employed unqualified providers which, in turn, increased the risk that his staff provided less than adequate quality of care.

The Division of Medical Assistance and Health Services, within the New Jersey Department of Human Services, administers New Jersey’s Medicaid program. Medicaid is a program through which individuals with disabilities and/or low incomes receive medical assistance. The Medicaid program provides intensive in-community mental health rehabilitation and behavioral assistance services to improve or stabilize children or young adults’ level of functioning within the home and community. These services, which are overseen by the Department of Children and Families (DCF) when provided to youth and children, seek to prevent, decrease, or eliminate behaviors or conditions that may place the individual at an increased clinical risk or otherwise negatively affect a person’s ability to function. These services are provided within the context of an approved plan of care and are restorative or preventative in nature.

Yi, a licensed clinical social worker, located in Princeton, New Jersey, has participated in the Medicaid program as an intensive in-community mental health rehabilitation and behavioral assistance services provider since April 18, 2016. Yi billed the Medicaid program for such services under Healthcare Common Procedure Coding System (HCPCS) codes H0036 and H2014. For the sampled claims, Yi, using his Medicaid provider number, billed for services that he personally rendered as well as services rendered by other professionals with whom he contracted. Accordingly, references to Yi include services performed by Yi as well as those performed by other behavioral health professionals.^[2]

The objective of this audit was to evaluate claims billed by and paid to Yi to determine whether Yi billed these claims in accordance with applicable state regulations.

The scope of the audit was September 21, 2016 through March 2, 2020. OSC conducted this audit pursuant to its authority set forth in N.J.S.A. 52:15C-1 to -23, and the Medicaid Program Integrity and Protection Act, N.J.S.A. 30:4D-53 to -64.

OSC selected a probability sample of 37 service days representing 963 claims, totaling $200,776 paid to Yi, from a population of 1,164 service dates representing 25,350 claims totaling $5,192,149 paid to Yi under HCPCS codes H0036 and H2014.

OSC reviewed Yi’s records related to 963 claims to determine whether the documentation provided complied with the requirements of New Jersey Administrative Code (N.J.A.C.) 10:49-9.8(a), N.J.A.C. 10:49-9.8(b)(1), N.J.A.C. 10:49-9.8(b)(3), N.J.A.C. 10:49-9.8(b)(4), N.J.A.C. 10:77-4.8(b), N.J.A.C. 10:77-4.9(e), N.J.A.C. 10:77-4.9(f), N.J.A.C. 10:77-4.9(g), N.J.A.C. 10:77-4.12(d)(3), -(5), N.J.A.C. 10:77-4.12(e)(6), N.J.A.C. 10:77-4.14(c)(1), N.J.A.C. 10:77-4.14(c)(2), N.J.A.C. 10:77-4.14(c)(4), N.J.A.C. 10:77-4.14(d)(1), N.J.A.C. 10:77-4.14(d)(2), N.J.A.C. 10:77-5.7(c), N.J.A.C. 10:77-5.7(d), N.J.A.C. 10:77-5.10(b), N.J.A.C. 10:77-5.12(d)(3), -(5), N.J.A.C. 10:77-5.12(e)(6), and N.J.A.C. 10:77-5.14(b).

The release of this Final Audit Report concludes a process during which OSC afforded Yi multiple opportunities to provide input regarding OSC’s findings. Specifically, OSC provided Yi a Summary of Findings (SOF) and offered Yi an opportunity to discuss the findings at an exit conference. OSC and Yi, represented by counsel, held an exit conference during which the parties discussed OSC's findings in the SOF. After the exit conference, Yi provided OSC additional records. After considering Yi’s submission, OSC provided Yi with a Draft Audit Report (DAR). Yi provided a formal response to the DAR, which is attached as Appendix M (“Yi’s Response to Draft Audit Report”).  

In his response to the DAR, Yi provided a corrective action plan that referenced revised policies and procedures to address OSC’s recommendations, but nonetheless objected to OSC’s sampling and extrapolation methodology as well as the audit findings. Yi also failed to indicate whether he intended to repay the identified overpayment. OSC addresses each argument raised by Yi in Appendix N (“Yi’s Comments and OSC’s Responses”).

A.  Yi Maintained Inaccurate and Incomplete Records

The Service Delivery Encounter Delivery (SDED) form is required by DCF to be completed by all intensive in-community and behavioral assistance services providers, and the form is available through the DCF website. DCF also provides detailed instructions to the providers on how to complete these necessary SDED forms. The purpose of the SDED form is to record and provide documentation for all encounters of intensive in-community and behavioral assistance services. The form is two pages. Page one includes fields for the beneficiary’s name, date of birth, address, the name and signature of the servicing provider, and an agency (provider) signatory certification. Page one also contains fields for service authorization information, as well as the name and license number of the clinical supervisor. Page two includes fields for the service encounter date, time, and delivery location, and the name of the guardian or responsible party, their address, and signature, and the date of service. This form aligns with the state Medicaid regulations that require providers to maintain records for each encounter, including the name and address of the beneficiary; the exact date, location and time of service; the type of service; and, the length of time for the face-to-face encounter. This form must be accurately completed for every service encounter between a provider and beneficiary, and must be signed and dated by both the servicing provider who rendered the service and the beneficiary or their parent/legal guardian. In sum, the SDED form not only documents the services provided and frequency of such services, but also serves to ensure that appropriately credentialed providers rendered services. 

OSC requested SDED forms (both pages) to determine whether Yi accurately completed and maintained required documentation for all intensive in-community and behavioral assistance provider encounters. OSC found that for 265 of the 963 sample claims, totaling $52,459 in reimbursement, Yi billed for services for which he failed to possess adequate documentation. The 265 failed claims contained 273 total exceptions.

• For 113 of the 273 exceptions, Yi failed to provide page one and/or page two of the SDED form for the sampled dates of service.
• For 55 of the 273 exceptions, Yi provided SDED forms that were missing signatures of the servicing providers attesting that the services were rendered.
• For 105 of the 273 exceptions, Yi submitted SDED forms on which the service delivery date noted on page two was outside of the prior authorization date (start and end date) specified on page one of the SDED form.

Recording correct prior authorization information on page one is important because, when compared to the service delivery date on page two, it ensures that the provider who is attesting to the accuracy of the information contained in the form actually delivered services during the authorized service delivery period. Additionally, by affixing a signature, the servicing provider attests that the provider delivered the services. OSC determined that, taken together, Yi’s SDED documentation was deficient because OSC could not determine whether the information contained on page one properly belonged to the document identified as the corresponding page two, and whether the attestations on page one properly related to the service delivery date captured on page two of the form. For example, page one of an SDED form noted that the prior authorization date range was February 15, 2019 (start date) through April 21, 2019 (end date).  However, the service date noted on page two was July 29, 2019, which occurred more than three months after the specified date range, thus making the SDED form unreliable. In sum, based on these issues, OSC determined that for these 265 claims, Yi’s SDED forms were not a reliable basis to support the claims.

By failing to maintain appropriate records, Yi violated N.J.A.C. 10:49-9.8(a) and N.J.A.C. 10:49-9.8(b)(1).

Pursuant to N.J.A.C. 10:49-9.8(a), “providers shall certify that the information furnished on the claim is true, accurate, and complete.”

Pursuant to N.J.A.C. 10:49-9.8(b)(1), providers are required “[t]o keep such records as are necessary to disclose fully the extent of services provided [.]”

Further pursuant to N.J.A.C. 10:49-9.8(b)(3), providers who fail to maintain appropriate records that document the extent of services billed agree that “payment adjustments shall be necessary [.]”

B.  Yi Billed Unsubstantiated Services

OSC reviewed records to determine whether Yi maintained proper documentation for services billed to Medicaid. OSC found that for 311 of the 963 sample claims, totaling $28,468 in reimbursement, Yi billed for services for which he failed to possess accurate documentation. Specifically, the hours of service on the SDED form conflicted with hours billed and paid. For example, one SDED form documented that one servicing provider rendered services on May 1, 2019, from 5:00 PM to 6:00 PM (one hour), but Yi billed Medicaid for two hours and thirty minutes for the same service, a difference of one hour and thirty minutes.

By failing to maintain appropriate records, Yi violated N.J.A.C. 10:49-9.8(a) and N.J.A.C. 10:49-9.8(b)(1).

Pursuant to N.J.A.C. 10:49-9.8(a), “providers shall certify that the information furnished on the claim is true, accurate, and complete.”

Pursuant to N.J.A.C. 10:49-9.8(b)(1), providers are required “[t]o keep such records as are necessary to disclose fully the extent of services provided.”

Further, pursuant to N.J.A.C. 10:49-9.8(b)(3), providers who fail to maintain appropriate records that document the extent of services billed agree that “payment adjustments shall be necessary[.]”

C.  Yi Upcoded Services Provided

For each Medicaid beneficiary receiving intensive in-community services, the provider must perform a needs assessment and clinical evaluation to determine the level and type of service that is medically necessary to address the identified issues. Intensive in-community services include three different levels of service: supportive services, professional services, and clinical services. Similarly, for those in need of behavioral assistance services, the provider must develop a service plan based on an evaluation of the beneficiary’s needs. From that plan, the provider must obtain prior authorization to bill specific services.

OSC reviewed Yi’s records to determine whether he billed for services at the appropriate level using the proper billing procedure code. OSC found that for 18 of the 963 claims, totaling $1,246 in reimbursement, Yi billed for services using a higher reimbursed procedure code and/or modifier than appropriate, which resulted in Yi receiving overpayments. For example, on October 18, 2018, a licensed social worker rendered service to a Medicaid beneficiary who was prior authorized to receive clinical services (clinical level), a higher level service than the service provided by the licensed social worker. Yi billed this encounter as a clinical level service even though the person who performed the service was a licensed social worker. Such billing resulted in Yi receiving the highest reimbursement amount for the lowest level of services actually provided.

By billing an inappropriate level of services and/or by upcoding, for these claims, Yi violated N.J.A.C. 10:49-9.8(a).

Pursuant to N.J.A.C. 10:49-9.8(a), “providers shall certify that the information furnished on the claim is true, accurate, and complete.”

Further, pursuant to N.J.A.C. 10:49-9.8(b)(4), providers agree “[t]hat the services billed on any claim and the amount charged therefore, are in accordance with the requirements of the New Jersey Medicaid and/or NJ FamilyCare programs[.]”

D.  Yi Billed for Services Provided to Different Beneficiaries at the Same or Overlapping Times

State Medicaid regulations regarding intensive in-community mental health and behavioral assistance services require providers to maintain true, accurate and complete records for each encounter documenting the name and address of the beneficiary; the exact date, location and time of service; the type of service; and the length of face-to-face contact time. This information is contained in the SDED form. As discussed above, this two-page form, which must be signed and dated both by the servicing provider who rendered the service, and the beneficiary or their parent/legal guardian, must be completed for every service encounter between a provider and beneficiary.

OSC reviewed Yi’s records, including the SDED forms, to determine whether Yi sufficiently documented the services rendered. Specifically, OSC compared the encounter dates and times recorded on the SDED forms to determine if claims overlapped in time. OSC found that for 9 of the 963 sample claims, totaling $921 in reimbursement, Yi billed for services provided by the same servicing provider to several beneficiaries at the same or overlapping time(s). For example, one SDED form documented that one servicing provider rendered services on April 30, 2019 from 2:30 PM to 5:00 PM. A second SDED form for that same date documented that the same servicing provider provided services to a different Medicaid beneficiary from 2:30 PM to 5:00 PM, resulting in an overlap of the entire encounter for two hours and thirty minutes (2:30 PM to 5:00 PM).

By improperly billing for overlapping services, Yi violated N.J.A.C. 10:49-9.8(a), N.J.A.C. 10:77-4.12(d)(3), -(5), and N.J.A.C. 10:77-5.12(d)(3), -(5).

Pursuant to N.J.A.C. 10:49-9.8(a), “providers shall certify that the information furnished on the claim is true, accurate, and complete.”

Further, pursuant to N.J.A.C. 10:49-9.8(b)(3), providers who fail to maintain appropriate records that document the extent of services billed agree that “payment adjustments shall be necessary[.]”

Pursuant to N.J.A.C. 10:77-4.12(d)(3), -(5) and N.J.A.C. 10:77-5.12(d)(3), -(5), providers shall maintain documentary support of all behavioral assistance services and intensive in-community mental health rehabilitation services claims including “[t]he exact date(s), location(s) and time(s) of service.” In addition, these provisions state that providers must maintain documentary support for “[t]he length of face-to-face contact [time], excluding travel time to or from the location of the beneficiary contact.”

E.   Yi Improperly Billed for Travel Time

OSC reviewed records to determine whether Yi improperly billed for travel time that was included within the length of face-to-face time that the servicing provider interacted with the beneficiary. OSC found that for 24 of the 963 claims, totaling $707 in reimbursement, Yi improperly billed for travel time to and/or from the location of the beneficiary as part of his billing for face-to-face services. For example, one SDED form documented that one servicing provider rendered services to a beneficiary on August 22, 2018 from 9:00 AM to 11:00 AM. A second SDED form for that same date documented that the same servicing provider rendered services to a different beneficiary from 11:00 AM to 1:00 PM. According to Google Maps, the two service encounter locations were 40.6 miles apart, requiring approximately 40 minutes of travel time. In that instance, Yi improperly billed travel time as part of his face-to-face services and, as such, did not account for any time needed for travel.

By improperly billing for travel time for the services provided, Yi violated N.J.A.C. 10:49-9.8(a), N.J.A.C. 10:77-4.12(d)(3), -(5), and N.J.A.C. 10:77-5.12(d)(3), -(5).

Pursuant to N.J.A.C. 10:49-9.8(a), “providers shall certify that the information furnished on the claim is true, accurate, and complete.”

Pursuant to N.J.A.C. 10:77-4.12(d)(3), -(5) and N.J.A.C. 10:77-5.12(d)(3), -(5), providers shall maintain support of all behavioral assistance services and intensive in-community mental health rehabilitation services claims including “[t]he exact date(s), location(s) and time(s) of service.” In addition, these provisions state that providers must maintain support for “[t]he length of face-to-face contact, excluding travel time to or from the location of the beneficiary contact.”

F.   Yi Failed to Document Services with Progress Notes

For both intensive in-community mental health rehabilitation and behavioral assistance services, the servicing provider must document services provided through progress notes. These notes provide relevant information regarding the treatment provided, the beneficiary’s response to the treatment, significant events that may affect the beneficiary’s condition or treatment, and other information pertinent to the beneficiary’s plan of care. The progress note differs from the SDED form in that the servicing provider completes the progress note, whereas the parent/guardian signs the SDED as an attestation as to the session’s date, duration, and location.

OSC reviewed Yi’s records to determine whether Yi maintained progress notes that supported his billed services. OSC found that for 37 of the 963 claims, totaling $7,697 in reimbursement, Yi failed to document services with a progress note.

By failing to maintain appropriate records for these claims, Yi violated N.J.A.C. 10:49-9.8(b)(1), N.J.A.C. 10:77-4.12(e)(6), and N.J.A.C. 10:77-5.12(e)(6).

Pursuant to N.J.A.C. 10:49-9.8(b)(1), providers are required “[t]o keep such records as are necessary to disclose fully the extent of services provided.”

Further, pursuant to N.J.A.C. 10:49-9.8(b)(3), providers who fail to maintain appropriate records that document the extent of services billed agree that “payment adjustments shall be necessary[.]”

Pursuant to N.J.A.C. 10:77-4.12(e)(6), the provider shall maintain, “[w]eekly quantifiable progress notes toward defined goals as stipulated in the child/youth or young adult’s BASP.”

Pursuant to N.J.A.C. 10:77-5.12(e)(6), the provider shall maintain “[f]or each discrete contact with the child/family, progress notes which address the defined goals stipulated in the child/youth or young adult's plan of care must be completed.”

G.  Yi Failed to Maintain Behavioral Assistance Training Certification for Behavioral Assistants

Pursuant to state regulations, intensive in-community mental health rehabilitation and behavioral assistance service providers must maintain written documentation showing that their Behavioral Assistants (BAs) successfully completed the Behavioral Assistance Training Certifications required by DCF. As part of the Behavioral Assistance Training Certification process, every BA must attend live trainings, meet 13 core competencies, and successfully pass a 30 question multiple-choice review. To be eligible to work as a BA, each BA must obtain the certification no later than six months after the BA’s hire date, and every BA must be recertified annually thereafter in order to continue providing BA services. Providers are responsible for verifying and maintaining evidence that their BAs obtained their certifications.

OSC requested that Yi provide the Behavioral Assistance Training Certifications for each BA in OSC’s sample claim to determine whether Yi satisfied the requirement that he verified and maintained this documentation. OSC found that Yi allowed 4 of 15 BAs in the audit sample selection to provide behavioral assistance services to beneficiaries without having obtained the required certification within six months from their hire date. Specifically, OSC found that Yi allowed untrained BAs to provide behavioral assistance services and inappropriately billed for 10 of the 963 claims, totaling $1,024 in reimbursement. For example, for three BAs, who accounted for 8 of the 963 claims, totaling $790 in reimbursement, Yi failed to provide any supporting documentation that he ever obtained the required Behavioral Assistance Training Certifications. Further, for the remaining BA, who accounted for 2 claims, totaling $234 in reimbursement, Yi did not provide documentation demonstrating the BA was certified on the date of service.

By failing to obtain such certificates within six months of hire date and re-certifications annually thereafter, Yi violated N.J.A.C. 10:77-4.14(c)(4).

Pursuant to N.J.A.C. 10:77-4.14(c)(4), the provider must maintain “[v]erified written documentation of the direct care staff person’s successful completion of any Behavioral Health Assistance Rehabilitation Services training required by the Department of Children and Families.”

H. Yi Failed to Maintain Proof of Education for Behavioral Assistants

According to state regulations, to perform behavioral assistance services, a BA must have, at a minimum, a high school diploma or equivalent. A Provider must verify and maintain proof that BAs satisfy this educational requirement.

OSC requested that Yi provide copies of high school diplomas or equivalents for each BA to determine whether qualified individuals performed services and to determine whether Yi possessed proof that these BAs had satisfied the minimum educational requirement. OSC found that Yi lacked the requisite documentation for 6 of the 15 BAs in the audit sample selection, which accounted for 19 of the 963 claims, totaling $1,940 in reimbursement.

By not obtaining and maintaining proof of education, Yi violated N.J.A.C. 10:77-4.9(e) and N.J.A.C. 10:77-4.14(c)(1).

Pursuant to N.J.A.C. 10:77-4.9(e), “[a]ll direct care staff shall, at a minimum, have a high school diploma or equivalent, be 21 years old and have a minimum of one year relevant experience in a comparable environment and shall be supervised by appropriate clinical staff in accordance with this subchapter.”

Pursuant to N.J.A.C. 10:77-4.14(c)(1), the provider must maintain “[a] copy of the direct care staff person’s high school diploma or equivalent.”

I. Yi Failed to Maintain a Criminal Background Check for a Behavioral Assistant Prior to Rendering Services

Pursuant to state regulations, intensive in-community mental health rehabilitation and behavioral assistance service providers must ensure that successful background checks are performed on employees who have direct contact with or render behavioral assistance services to beneficiaries. State regulations further require providers to maintain evidence that a “recognized and reputable” entity successfully completed these criminal background checks.

OSC requested documentation to determine whether Yi maintained evidence of successfully completed criminal background checks for each BA prior to the BA providing services to beneficiaries. OSC found that Yi allowed one BA in the audit sample to provide behavioral assistance services to beneficiaries prior to obtaining a criminal background check for the BA. Specifically, OSC found that Yi billed for behavioral assistance services for 1 of the 963 claims, totaling $78 in reimbursement, without having first obtained a criminal background check.

By failing to obtain a successful criminal background check before his employee provided services to Medicaid beneficiaries, Yi violated N.J.A.C. 10:77-4.9(g) and N.J.A.C. 10:77-4.14(d)(2).

Pursuant to N.J.A.C. 10:77-4.9(g), “[a]ll employees having direct contact with and/or rendering behavioral assistance services directly to the beneficiaries shall be required to successfully complete criminal background checks.”

Pursuant to N.J.A.C. 10:77-4.14(d)(2), the provider must maintain “[v]erified written documentation of successful completion of a criminal background check conducted by a recognized and reputable search organization for all staff having direct contact with children.”

J. Yi Failed to Maintain a Current and Valid Driver’s License for a Behavioral Assistant

Behavioral assistance services provided to beneficiaries, up to 21 years of age, often occur outside of their place of residence, in playgrounds and in other in-community settings. For such services, BAs may drive beneficiaries to the service location. As such, state regulations require all BAs to have a current and valid driver’s license and require providers to maintain a copy of each BA’s valid driver’s license.

OSC requested documentation to determine whether Yi maintained a copy of each BA’s current and valid driver’s license. OSC found that for 1 BA in the audit sample, which accounted for 1 of the 963 claims, totaling $78 in reimbursement, Yi failed to maintain a copy of a BA’s current and valid driver’s license.

By failing to maintain a copy of a current and valid driver’s license, Yi violated N.J.A.C. 10:77-4.9(f) and N.J.A.C. 10:77-4.14(d)(1).

Pursuant to N.J.A.C. 10:77-4.9(f), “[a]ll employees shall have a valid driver's license if his or her job functions include the operation of a vehicle used in the transportation of the children/youth or young adults. Transportation is not a covered behavioral assistance service.”

Pursuant to N.J.A.C. 10:77-4.14(d)(1), “[a] copy of his or her current valid driver’s license, if driving is required to fulfill the responsibilities of the job,” is required to be maintained by the provider.

K. Yi Failed to Maintain Proof of Minimum Age Documentation for a Behavioral Assistant

Pursuant to state regulations, a BA must be at least 21 years old to perform behavioral assistance services. OSC found that for 1 BA in the audit sample, which accounted for 1 of the 963 claims, totaling $78 in reimbursement, Yi failed to maintain proof of age for a BA performing services.

By failing to maintain the proof of age, Yi violated N.J.A.C. 10:77-4.9(e) and N.J.A.C. 10:77-4.14(c)(2).

Pursuant to N.J.A.C. 10:77-4.9(e), “[a]ll direct care staff shall, at a minimum, have a high school diploma or equivalent, be 21 years old and have a minimum of one year relevant experience in a comparable environment and shall be supervised by appropriate clinical staff in accordance with this subchapter.”

Pursuant to N.J.A.C. 10:77-4.14(c)(2), “[f]or the direct care staff employed by the agency, the following information shall be maintained: . . . 2. A copy of the direct care staff person’s proof of age at the date of hiring.”

L.   Summary of Medicaid Overpayment

OSC determined that from its audit of 37 randomly selected service dates for the period from September 21, 2016 through March 2, 2020, Yi billed 33 service dates that contained errors. Yi improperly billed and received payment for 518 of the 963 sample claims, totaling $75,423 in reimbursement. These 518 failed claims contained 704 total exceptions, as some claims failed for multiple reasons. To ascertain the overpayment Yi received, OSC extrapolated the error dollars ($75,423) for the 33 service dates, or 518 unique claims that failed to comply with applicable regulations, to the total population from which the sample service dates were drawn, which in this case was 1,164 service dates, or 25,350 claims, with a total payment amount of $5,192,149. From this extrapolation, OSC calculated that Yi received an overpayment of at least $1,795,277 that he must repay to the Medicaid program.^[3]

Yi shall:

1. Reimburse Medicaid the overpayment amount of $1,795,277.

2. Adhere to state regulations for all Medicaid services provided by Yi and the health care professionals he employs.

3. Obtain and maintain required documentation for each behavioral assistant (i.e., successfully completed criminal background checks, valid driver’s licenses, proof of education and proof of age) before behavioral assistants are assigned any case referrals, to ensure compliance with state regulations.

4. Ensure that all professionals employed by Yi receive training to foster compliance with applicable state regulations.

5. Provide OSC with a Corrective Action Plan indicating the steps Yi will take to implement procedures to correct the deficiencies identified herein.