Dr Linda Shelton, who has devoted her life to service of others and particularly to providing medical and mental health services to the poor will be completely destroyed in two weeks with a false conviction for Illinois Medicaid Fraud simply for trying to help people on Medicaid obtain mental health care. Please read the following and help any way possible. I thank anyone who will help me.
This is a story epitomizing government corruption and greed, retaliation against whistle blowers, and gross government incompetence brought on by decades of fraud, patronage, and nepotism in Illinois.
Judge Jorge Alonso ruled on my pending criminal case where I am charged with Medicaid fraud that “substitute billing is illegal”. This is where a doctor sends a bill to the insurance company for services performed by his employee such as the service of a nurse administering a vaccine or a psychologist administering a psychological test, or a cast technician applying a cast. In my case the Illinois Attorney General claims that if a doctor bills Medicaid for counseling (for drug addiction, post-traumatic-stress disorder after rape, obsessive-compulsive disorder, depression, dementia, etc.) if the counseling or psychological testing was done by an employee and not directly by the physician then it is a felony crime.
If substitute, also known as incident to, billing is illegal than ALL doctors in Illinois are guilty of a felony crime of fraud! God Help Us! Judge Alonso is so eager to railroad me and convict me that he is violating his oath of office to uphold the laws of the land and the constitution. Due process, guaranteed by the Bill of Rights REQUIRES that he follow the law. He is BLATANTLY violating the law, either maliciously or ignorantly due to his arrogance, incompetence, bias to run and support the alleged prosecutor AG Lisa Madigan, or his ego.
Physicians are NOT trained to do psychological testing for personality disorders or mental illness. Psychologists at the master’s and Ph.D level are trained to do so. These tests are invaluable in helping determine the right diagnosis and the right course of treatment. Judge Alonso has ruled that those on Medicaid are not eligible for this type of evaluation and treatment as a result of his illegal and unconstitutional ruling.
Many non-physicians are licensed in Illinois and all states to provide Psychiatric & Psychological Services:
1. nurses 225 ILCS 65,
2. clinical psychologists 225 ILCS 15,
3. licensed social workers 225 ILCS 20,
4. licensed clinical professional counselor 225 ILCS 107,
5. licensed marriage and family therapist 225 ILCS 55 and 68 ILAC 1283
Judge Alonso’s illegal ruling denies all of these people the RIGHT to practice their profession and denies the citizens of Illinois on Medicaid the Right under the Federal Medicaid Act to access to care equivalent to the care provided in the community.
Federal Judge Joan Lefkow ruled in August 2004, at the end of a 12 year civil rights class action suit that “Illinois Medicaid Policies and Procedures are in Violation of the Federal Medicaid Code because they Deny Access to Care” to children on Medicaid. This ruling is applicable to all Medicaid patients but the ruling only applies to children. It needs to be expanded to cover all Medicaid patients.
The Federal Medicaid Code, 42 U.S.C. 1396A(a)(30)(A), [regarding adults and children covered under Medicaid and the EPSDT program] REQUIRES any State Medicaid program funded by the federal government to provide care equivalent to that obtainable from private insurers in the community to Illinois Medicaid clients.
Therefore, Judge Alonso’s ruling is unconstitutional, unfair, illegal, and amounts to his ruling to overturn the Federal Medicaid Code as well as Illinois Statutes licensing non-physician providers of mental health services. As > 80 % of mental health services are provided by non-physicians this essentially shuts out mental health services to all but a few in Illinois who are poor.
The Federal Court and U.S. Attorney should intervene as this is illegal and also a violation of the Americans with Disabilities Act in terms of discrimination.
As to my case, I am charged with billing for mental health services never done and substitute billing for mental health services between June 2000 and April 2002 while “working” at Right Frame of Mind & Associates (RFOM). Over the last six months when I obtained access to the old business records for RFOM I discovered the fact is that the year before I started working for a group practice called RFOM, part-time providing chart review for quality, consultation about medical and psychiatric policies and procedures, and limited patient care, two woman, who were partners with the CEO and without the knowledge of the CEO, in 2000 fabricated hundreds of patient encounter forms (filled out by doctors or therapists as to what patient they saw, the diagnosis, and what service was provided), that are later translated into bills or invoices by the billing agent, for services they never did. These two women, Itadel Shalabi and Nareman Taha never met me as they were fired before I started working there in 2001.
I had major neurosurgery in July 2000 due to a congenital spinal problem that was crushing my spinal cord and leading progressively towards quadraplegia. I was incapacitated for six months and heavily sedated with narcotics and other drugs for much of that time. I had agreed in early 2000 at the request of the CEO to be one of a dozen or more part-time medical directors to oversee quality of care, screen for medical disorders mimicking psychiatric disorders, help train the counselors to write better notes (many were foreigners with good counseling skills but a little difficulty with English writing), advise the CEO on best medical practices and standard of care, and provide physician services to patients needing medications.
I or my staff while I was in hospital gave the CEO my Medicaid provider number and other necessary documents so that the company’s billing agent Louise Moore of Data Medical Works could sign me up with Medicaid as a provider for the group so that they could bill for my services when I began to work, if I recovered, in 2001.
Ms. Moore I never met at the time was a sweet lady who is ignorant of a lot of things. She held herself out to be a expert at medical billing and she signed a contract with the CEO in early 2000 to set the group up legally to bill Medicaid. Nothing she did was actually proper, but it was not her own fault. She failed to tell the CEO he would be paid more if he had his group certified as a community mental health center. She was totally ignorant of the concept of community mental health centers (or the drug addiction and alcohol treatment centers – another center with its own enabling State Statue).
Under the Community Mental Health Service Act mental health groups that become certified bill Medicaid under the Center’s name and not under the doctor’s name. They also contract with the Illinois prisons, and/or DCFS (Illinois Child Welfare) or other agencies to provide comprehensive mental health services. They must have at least one medical director, but the director is an administrator and doesn’t have to see patients. Ph.D. psychologists or doctors or licensed mental health providers can supervise non-physician mental health service providers and bills can be sent in to Medicaid under the center’s name for all these services.
Ms. Moore ignorantly thinking (falsely) that her contract allowed her to sign the names of Right Frame of Mind employees on to any form signed my name in August and December 2000, without my or the CEO’s knowledge or consent, on a power of attorney form, an alternate payee form, and a blue cross/blue shielf electronic partner trading agreement form, which are all required to allow her to translate the patient encounter form to an electronic invoice and send it over the wire to BC/BS for adjudication, who then sends it to Medicaid, who then pays abut 30-40 cents on the dollar to the Alternate Payee (in this case RFOM).
Ms. Moore had spoken to the Medicaid Provider Service Unit about how to register the non-physician providers to bill Medicaid. She was told that non-physicians cannot bill Medicaid, was NOT told that a better way to bill was as a community mental health center or how to sign the group up as a community mental health center, and told that all bills (invoices) had to have a doctor’s name as the provider.
Then Ms. Moore, without my or the CEO’s knowledge changed the provider name in preparing invoices from Itadel Shalabi’s and Nareman Taha’s fraudulent patient encounter forms to my name so she could bill under my Medicaid Provider Number. I don’t believe that Ms. Moore had ANY knowledge of the fraudulent nature of the Patient Encounter Forms made by these two women.
Therefore the ghost billing charge is a result of ID Theft, resulting from both fraud by these two women and a comedy of errors by incompetent people advising Ms. Moore in the Medicaid Provider Service Unit, as well as her own blundering ignorance. I am totally innocent having not participated in any way in generating these bills or in receiving or using the money paid for them by Medicaid.
Ms Moore unfortunately is also guilty of mass fraud in all the work she has done in the past decade or more. It is illegal for an insurance biller to bill Medicaid based on a contract where they are paid by the percentage of funds received from Medicaid by the provider. Ms. Moore charged around 8% of all billings. This is illegal and considered fraud as it ties the billers service, which has nothing to do with the medical care provided, with the doctor’s service. Therefore, if she billed for a $100,000 procedure by a heart surgeon she would be paid $8,000 for sending in one bill, while when a family doctor bills $100, she would be paid $8. Providers of services to doctors are NOT ALLOWED to tie their services to the income from the actual medical provider. She MUST BILL ONLY by the piece of work such as $8 per bill. However, she has not been indicted for Medicaid Fraud and has not been sued by RFOM for Fraud in holding herself out to be an expert on billing when she was not.
The second aspect of the charge is substitute billing. I signed a Power of Attorney Form and Alternate Payee Agreement in August 2001. I was informed by the CEO sometime in late 2001 or early 2002 that the group was told by Ms. Moore that the counselors’ and psychologists’ services had to be billed under a doctor’s name so that bills on patients I had seen, but for dates of service when they were seen by a non-physician were being billed under my name. I had assumed that the billing agent was competent and doing the billing properly. I had assumed that substitute billing for employees services in mental health care was as legal as billing Medicaid for my nurse giving a patient a vaccine. I had no idea at the time that anyone considered substitute billing illegal. I had no knowledge that Ms. Moore had actually sent in tens of thousands of dollars worth of bills under my name before August 1, 2001 based on documents she forged and the fraudulent patient encounter forms from the above two women. Therefore, I told the CEO that was fine. I was not involved in billing or administration of the group except to fill out patient encounter forms when I saw a patient. I had a good faith belief that all was well.
I had also had an agreement that being part-time the business would limit my patient panel to 200 patients as I did not feel that part-time doctors should supervise the care of any more patients than this number.
Since Judge Alonso has unconstitutionally and illegally ruled that substitute billing is illegal I will be found guilty and likely sentence to prison for 4-15 years, as well as forever lose my medical license and reputation, along with my livelihood, future, friends, health as medical care is inadequate in prison and I am disabled with several serious medical disorders, and will to live. I have informed the U.S. Attorney, FBI, at the time Senator Obama, Senator Durbin, and now Senator Burris along with a lot of Congressmen and other Sentators and State legislators. I am receiving no assistance to solve this problem and restore mental health care in Illinois to those on Medicaid.
In late 2001 Ms. Lovett, Ms. Collins and others from the Office of Inspector General Medicaid contacted the RFOM and claimed that they needed to review some charts as a “standard review of a new practice to help us comply with the rules”. We completely complied and Ms. Lovett came out in 2001. She told the CEO the charts were well done and she would give us a report in 90 days. The CEO was actually very happy about this review because he wanted to make sure that our group practiced with the highest quality and had the best quality charting in the business. They never gave us a report or any feedback and their only response was to initiate a felony prosecution which culminated in the indictment of selectively me (and not one other of the dozen or so medical directors doing the same job – perhaps because only the CEO and I were whistle blowers about Illinois Governement Corruption and mistreatment of children in foster care and on Medicaid by the State) and the CEO.
After a number of months with NO feedback and strange comments from the Illinois State Police Medicaid Fraud Unit (part of the Illinois Attorney General’s Office), where the CEO had gone to inform them that he was concerned abut the integrity of our medical records because he had fired Itadel Shalabi and Nareman Taha for other administrative misconduct and inappropriate behavior with patients and they stole a hundred or so medical records (eventually returning parts of them) I began my own investigation of the rules of Medicaid. The State Police have not arrested them yet.
The CEO, I had learned over about a year was much more naive than I thought about running the business. I had assumed that he was qualified as an administrator and found out he was not. Finding out about the stolen charts and the lack of feedback from the OIG-Medicaid on this “routine review” concerned me. I was also concerned because in April 2002 the CEO told me that Ms. Collins at OIG-Medicaid had informed him to talk to Mr. Brown at Medicaid because there was a problem with the way our group was set up. Mr. Brown told the CEO that RFOM could not be a proper alternate payee under their rules and he apologized for misleading the CEO when the group was originally set up in 2000. He told the CEO that Medicaid could not continue to pay the group unless it was owned by the doctors. The group was the sole proprietorship of the CEO a master degreed psychologist. The CEO said OK, hired an attorney, and asked several of the doctors to be the officers of the group as it changed to corporate status. The corporation was set up so that the doctors would not actually profit from the corporation but were only paid by the hour for their work. The CEO was going to make a profit from managing the corporation. However, no profit was ever made as all the income went to overhead, particularly paying the counselors and doctors their salary and/or hourly rate. The CEO actually put in $100,000 of his own money to meet payroll before he closed the business as no viable financially. My total income from the group was about $5000 over all the time I worked there from 2001 to 2003. I always told the CEO to pay the other employees first and my work was only very limited and part-time.
Beginning in 2002, I researched the Federal and State Medicaid rules, policies, and laws so that I would be able to meet my fiduciary duty to participate in running the corporation at least from an advisory point of view. I discovered the following and this is why I told the CEO in mid 2002 and maintain this belief, that substitute billing is perfectly legal and actually REQUIRED by the Federal Medicaid Code as well as NOT PROHIBITED by Illiniois Statutes or Illinois Adminstrative Rules:
Federal and State Medicaid laws are extensive, complex, and immensely confusing. The State of Illinois is misusing them to indict doctors, psychologists, administrators of psychiatric and psychological practices for “Medicaid Fraud” when they are actually following federal law and providing needy services including counseling, drug treatment, suicide prevention, etc. Attorney General Lisa Madigan and Jim Ryan before her have targeted especially those groups run by whistle blowers, in order to falsely claim they are tough on fraud, to prevent Illinois from paying the bill for mental health services for the poor and needy on Medicaid, and reduce the bottom line.
A claim of “tough on fraud” will help AG Lisa Madigan win election as Governor. Failure to provide mental health care including drug addiction and alcoholism treatment leads to increased crime as drug addicts, alcoholics, and those that are so out of touch and mentally ill find alternatives to legitimate work to feed their habits or survive. Failure to provide adequate mental health care at the front end leads to much higher costs in the long run.
Code of Federal Regulations 42 CFR 414.34 states:
“Payment for services and supplies incident to a physician’s service”
“(b) Services of non[-]physicians that are incident to a physician’s service. Services of non physicians that are covered as incident to a physician’s service are paid as if the physician had personally furnished the service. ”
United States Code42 U.S.C. § 1396d(a)(5)(A)
requires reimbursement for “physicians’ services furnished by a physician.”
Code of Federal Regulations 42 C.F.R. § 440.50
The HHS rule implementing the Medicaid Act defines “physician services” to include services provided:
“(a) within the scope of practice of medicine or osteopathy as defined by State law; and
(b) by or under the personal supervision of an individual licensed under State law to practice medicine or osteopathy.”
United States Code42 U.S.C. §1396a(a)(32)(C)
Congress further authorized substitute billing under Medicaid for services furnished:
“by, or incident to the services” of another physician
Federal Regulation66 Fed. Reg. 55268
HHS makes clear in its preamble to this rule that it does not restrict the type of auxiliary personnel who may perform a given “incident to” service: “We deliberately used the term any individual so that the physician (or other practitioner), under his or her discretion and license, may use the service of anyone ranging from another physician to a medical assistant.”
Code of Federal Regulations42 CFR 411.15
“Particular services exclude from coverage” specifically states that:
“(m) (3) Exceptions. The following services are not excluded from coverage:
…
•(iii) Nurse practitioner and clinical nurse specialist services…
…
•(v) Qualified psychologist services,”
FEDERAL PREEMPTION SUSTAINED BY FEDERAL 2ND CIRCUIT COURT OF APPEAL
•A Federal suit for a psychiatrist against the New York Medicaid Program based on its refusal to approve Medicaid was agreed to for reimbursement for services provided by his employees under his supervision. Yapalater v. Bates, 494 F. Supp. 1349 (S.D.N.Y. 1980), aff’d, 644 F.2d 131 (2d Cir. 1981), cert. denied, 455 U.S. 908, 102 S. Ct. 1255 (1982).
•The court determined that the federal Medicaid rule at 42 C.F.R. §440.50 defining “physician services” unquestionably included supervisees other than the physician, just as the same rule must apply here to vacate Plaintiffs’ indictments. Id. at 1363-64.
State Medicaid must Provide Services 42 U.S.C. 1396a(a)30(A)
•Federal Code clearly mandates that State Medicaid plans must provide services to recipients of Medicaid and payment to their service providers equivalent to care and services provided to the general population by private insurers
•Private insurance pays for psychiatric services provided by counselors and psychologists
•RFOM CEO and other employees, besides the physicians were licensed counselors, nurses, psychological therapist, or social workers, per CEO
42 U.S.C. 1396a(a)30(A)
“A State plan for medical assistance must –
Provide such methods and procedures relating to the utilization of, and the payment for, care and services available under the plan . . . to assure that payments are … sufficient to enlist enough providers so that care and services are available under the plan … at least to the extent that such care and services are available to the general population in the geographic area“,
Ambiguous State Laws Must be Interpreted to Conform to Fed Law
•The Federal 7th Circuit Court of Appeals has also construed ambiguous state regulations to conform to federal Medicaid requirements,
•an approach worth revisiting here with respect to Sections 140.411 and 140.413 of the Illinois Administrative Code.
•See Evanston Hosp. v. Hauck 1 F.3d 540 (7th Cir.1993), cert. denied, 510 U.S. 1091 (1994).
I (SHELTON) CONTINUES HER OWN INVESTIGATION OF BILLING PRACTICES – 2002-2005
•Shelton discovers that Physician Medicaid Manual has inconsistencies, in one place stating bills for employees billed under doctor’s name, and in another place stating that no psychiatric services can be billed for non-physicians, yet in another place stating that non-physicians may provide psychiatric services and Medicaid may be billed. She also discovered the Illinois Community Mental Health Center Code.
Illinois Administrative Code (IAC)
89 IAC 140.12
“Services Not Covered by Physician”
DOES NOT MENTION psychiatric services by non-physicians
Illinois Administrative Code
89 IAC 140.400(a)
“Payment to Practitioners”
“2) A practitioner may bill only for services he or she personally provides or which are provided under his or her direct supervision in his or her office by his or her staff.”
Illinois Administrative Code
89 IAC 140.411
“Covered Services by Physicians”
“The Department shall pay physicians for the provision of services not otherwise excluded which are:
. . .
c) Provided by the physician or by a member of the physician’s staff under the physician’s direct supervision
Illinois Administrative Code
89 IAC 140.413
“Limitations on Physician Services”
that “limitations” on physician’s services include that psychiatric services will be paid for if they are “. . . provided by a physician . . .” [It does not exclude non-physician services and it is a reasonable inference to conclude the definition of “physician” include the services of non-physician employees, under the doctor’s supervision as defined in 89 IAC 140.400 & 411]
How does this negate previous definition of “physician services” which include incident services by his employees?
UNCONSTITUTIONAL STATE CLAIM
State falsely claims use of word “physician” in 89 IAC 140.413 negates definition of
“physician services”, which includes incident services by physician’s employees as defined in 89 IAC 140.400(a), 89 IAC 140.411
State falsely claims that federal law does not apply and statutory construction rules don’t apply
Judge Alonso previously illegally ruled that the Federal Medicaid Code does not apply in this case despite the fact the Illinois Medicaid is a joint federal/state program partially funded by the Federal Medicaid Code!
IAC TOO VAGUE
•Criminal Laws are invalid if too vague to understand (“void for vagueness doctrine”)
•Illinois Administrative Code too vague in sections:
89 IAC 140.12,
89 IAC 140.400,
89 IAC 140.411, and
89 IAC 140.413
Illinois Administrative Code
•Why should 89 IAC 140.413 have more weight than 89 IAC 140.12?
•Why should the definitions of physician services in and 140.411 not apply to the term “physician” in 89 IAC 140.413?
STATUTORY CONSTRUCTION RULES REQUIRE (Regarding interpretation of conflictin State Statutes)
Specific Controls over General
•89 IAC 140.400 & 89 IAC 140.411
more specific “physician services” includes non-physician employee services
•89 IAC 140.413 general word “physician” with no definition of what services this includes cannot by exclusion negate previous more specific definition of services provided by physician
Federal Law Rules
42 CFR 414.34
Services by Physician’s staff are billed as IF the Physician Performed the Services Himself
If State and Federal Law conflicts, Federal Law Rules
Due to the Supremacy Clause of the United States Constitution
FEDERAL LAW REQUIRES PAYMENT FOR EPSDT SERVICES
•The Federal Medicaid Code requires that State Medicaid programs pay for periodic mental health screening and treatment of any defects in mental health for children under 21:
• 42 USC 1396d “Definitions For purposes of this chapter
• (r) Early and periodic screening, diagnostic, and treatment services
•
•The term ‘early and periodic screening, diagnostic, and treatment services’ means the following items and services:
• (1) Screening services –
• (A) which are provided –
•(ii) at such other intervals, indicated as medically necessary, to determine the existence of certain physical and mental illnesses or conditions;
• . . .
•(5) Such other necessary health care, diagnostic services, treatment, and other measures described in subsection (a) of this section to correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening services, whether or not such services are covered under the State plan.”
STATE LAW REQUIRES PAYMENT FOR EPSDT SERVICES
•89 IAC 140.485 states:
•“Healthy Kids Program
•Program Description
–The Healthy Kids Program is the Early and Periodic Screening Diagnostic and Treatment Program [EPSDT] mandated by the Social Security Act (see 42 U.S.C. 1396a(43), 1396d(4)(B)(Supp. 1987)). The goals of the program are to:
•Improve the health status of Medicaid-eligible children ages birth through 20 years through the provision of preventive medical care and early diagnosis and treatment of conditions threatening the child’s health
•…
•8) Treatment. The Department shall pay for necessary medical care (see Section 140.2), diagnostic services [i.e. psychological testing], treatment or other measures medically necessary … to correct or ameliorate defects, physical or mental illnesses….”,
•The Illinois Public Aid Code [AKA Medicaid Act], 305 ILCS 5/19(f) requires that EPSDT screening and mental health treatment be provided to children in the Medicaid program:
•“5/19. Healthy Kids Program
•(f) Covered Medical Services. The Illinois Department shall provide coverage for all necessary health care, diagnostic services, treatment and other measures to correct or ameliorate defects, physical and mental illnesses, and conditions whether discovered by screening services or not for all children eligible for Medical Assistance under Article V of this Code.”
Dr Shelton was a Medicaid Registered EPSTD Provider
Therefore ANY REASONABLE person would conclude that the law permits substitute billing for mental health services whether it be another physician covering for the doctor, or a non-physician supervised by the doctor or her colleagues. If you don’t agree than the void for vagueness doctrine should clearly negate and prevent any criminal charges for substitute billing.
God Help Me! I am innocent and destroyed. This is my reward for devoting my life to service particularly of the poor and needy. If you want to help, contact the Illinois Reform Committee and flood them with letters. Contact the U.S. Attorney and FBI and flood them with letters. Contact your legislators and Congressmen and flood them with letters. Come to the trial on February 17, 2009 which will last two weeks and fill the gallery so that the judge knows your opinion. Contact the press. Donate to my legal fund anything possible. I need tens of thousands of dollars. Shelton Legal Fund, C/O Albukerk & Associates, 3025 W. 26th St. 2nd Floor, Chicago, IL 60623. Thank you if you help.
Dr Linda Shelton 