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Former V.I. Human Services Employee Charged With Embezzlement, Medicaid Fraud: VIDOJ

FREDERIKSTED — A former Medicaid eligibility supervisor for the Virgin Islands Human Services Department was charged Friday with lying on government forms to obtain Medicaid benefits that she was not eligible to receive, according to a warrant for her arrest.

Kathleen M. Gussie was charged with embezzlement by a public or private officer, embezzlement or falsification of public accounts, conversion of government property, and three counts of making fraudulent claims upon the government.

Gussie was released after posting 10 percent of the $50,000 bond and is scheduled to appear in court Monday.

The incidents occurred between December 11, 2017, to July 2018.

According to an affidavit in support of the arrest warrant, the investigation revealed that Gussie fraudulently obtained and used Medicaid funds for her benefit when she knew she was not lawfully eligible for Medicaid benefits.

Attorney General Denise George said this is the first of many arrests and prosecutions deriving from the Medicaid Fraud Control Unit (“VIMFCU”) at the VIDOJ.

“This is the first arrest, and we expect there will be many more. Within the last year alone, after being fully staffed with an investigator, analyst, director, and a legal assistant, we have gotten a substantial number of cases and complaints,” AG George said.

VIMFCU is required under both federal and territorial law, to partner with the Virgin Islands Department of Human Services to combat waste, fraud, and abuse in the Medicaid program.

DHS and VIDOJ entered a Memorandum of Understanding (“MOU”), wherein DHS agreed to refer all suspected cases of Medicaid fraud, abuse, and/or neglect to VIMFCU. VIMFCU will also partner with DHS to revise policies or make programmatic or legislative changes to the Medicaid program.

V.I. Human Services Commissioner Kimberley Causey-Gomez provided a statement during Friday’s briefing.

V.I. Human Services Commissioner Kimberley Causey-Gomez

“As demonstrated by today’s events, the Department of Human Services and our team’s leadership will not tolerate fraud, waste or abuse in any of our divisions, especially Medicaid, as we exist to serve our most vulnerable populations,” Causey-Gomez said.

VIMFCU was created as a division within the Virgin Islands Department of Justice as a result of federal legislation authorizing the states and territories to investigate and prosecute fraud and abuse in Medicaid.

It was first certified in DOJ in December 2018 and has been re-certified every year since. Medicaid Fraud Control Units, such as the one in the territory, operate in all 50 states, the District of Columbia, and Puerto Rico. The Division is 100 percent funded by a grant from the United States Department of Health and Human Services, Office of the Inspector General.

It protects the territory and its taxpayers by investigating and prosecuting fraud committed by those health care providers and facilities that provide services paid by Medicaid. Also, the VIMFCU protects the most vulnerable in this community by investigating and prosecuting complaints of elder and resident abuse or neglect in nursing homes, adult family homes, and assisted living.

VIMFCU also makes recommendations to the U.S. Department of Health and Health and Human Services, Office of the Inspector General to exclude individuals or entities from participating in federally funded programs.
VIMFCU has authority under both federal and local laws to hold medical providers or entities accountable through criminal prosecution and/or civil litigation.

Providers can include physicians (medical doctors), dentists, nursing or convalescent homes, medical equipment supply companies, taxi, and other transportation companies, or anyone else who bills the Virgin Islands Medicaid program for health care services provided to a Medicaid recipient.

To report fraud, the VIMFCU has a confidential phone number, 1-888-404-6328 and email mfcu@doj.vi.gov

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