The embattled behavioral health provider Gateway Community Services, the focus of pointed attacks by Maine Republicans and right wing activists, was referred to a health care crime unit for a fraud investigation before the state suspended the company’s MaineCare provider payments in December.
Additionally, law enforcement may have asked the state to delay the payment suspension because it would alert the provider about a probe.
Those details illustrate how the company faces greater scrutiny from regulators than previously known. It also reveals the complexities of investigating fraud in a $5.4 billion program that is largely monitored for irregularities by a small “program integrity unit” assessing MaineCare claims by more than 5,000 different providers.
Three separate audits by that unit have found Gateway overbilled MaineCare, the state’s Medicaid program, for more than $1.7 million. The most recent review was initiated in January 2023 and made public for the first time in December after regulators moved to suspend Gateway’s MaineCare payments.
Officials at the Maine Department of Health and Human Services, which oversees MaineCare, had previously acknowledged that overbillings of more than $100,000 are “higher than normal,” raising questions about why Gateway’s payments hadn’t been suspended sooner.
In response to questions from Maine Public, officials at DHHS acknowledged that the fraud referral to the Maine Office of Attorney General came before the payment suspension announcement on Dec. 23. The agency would not provide the exact date of the referral and such information is shielded from Maine’s public records law under investigative records exemptions.
Fraud referrals go to the Healthcare Crimes Unit, a specialized division within the state attorney general office that is primarily funded by the federal government. According to the MaineCare Benefits Manual, law enforcement investigating a provider may ask that regulators delay a payment suspension “because it may compromise or jeopardize an investigation.” A suspension also triggers a notice to that provider, which is allowed to appeal.
A spokesperson for the attorney general has declined to confirm whether it’s investigating Gateway, which is customary during ongoing investigations.
The third audit was initiated in 2023 after a data analysis signaled irregularities, according to DHHS. It found Gateway Community Services overbilled MaineCare by more than $1 million, primarily for interpreter-related services.
An attorney for the company has repeatedly denied allegations of wrongdoing.
The suspension announcement supercharged outcries from Republican lawmakers and aligned activists, as both have attempted to draw parallels to a systemic fraud scandal in Minnesota. Like Minnesota, the Gateway controversy has become the pretext for the Trump administration’s surge in federal immigration enforcement in Maine that potentially targets Somali Americans.
Gateway Community Services was founded by Abdullahi Ali, a Somali American.
“They’re scammers. They always will be, and we’re getting them out,” President Donald Trump said during an event at the Detroit Economic Club last week. “In Maine, it’s really crooked as hell, too.”
Since the December suspension announcement, Republicans in the Maine Legislature have accused the Mills administration of ignoring fraud in the state’s welfare system. Some, including state Sen. Trey Stewart, R-Presque Isle, have asserted that Democrats at the state and federal level have deliberately constructed the programs for abuse.
“This is fraud by design,” he said during a Dec. 30 press conference at the State House. “This didn’t just happen. It’s a system that’s designed by the left for people in their social circles.”
Referring to Gateway, he added, “This is just the tip of the iceberg.”
To emphasize that point, Republicans on Friday highlighted a new Office of Inspector General report finding that Maine made $45.6 million in improper payments to providers for autism services, a finding that could result in the state having to repay the federal government $28.7 million.
The report does not allege fraud, which is distinct from improper payments.
Assessing Medicaid fraud investigations
The heated political rhetoric surrounding the Gateway controversy has often elided the complexities of audits and fraud investigations. Officials performing those functions rarely comment publicly on specific cases, particularly after a fraud referral. That leaves partisans to fill the void.
Additionally, assessing Maine’s performance policing Medicaid fraud is difficult because of the way audits and investigations are conducted, often taking years to complete and adjudicate.
Officials at DHHS recently held a briefing for state lawmakers to walk them through the MaineCare program integrity process. Some were surprised to learn that auditing the sprawling program with thousands of providers falls to an eight-person unit within the Office of MaineCare Services.
Medicaid is a federal program that is administered by states. In Maine, most of MaineCare’s $5.4 billion in spending is funded by the federal government with the state kicking in about $1.5 billion annually. However, oversight largely falls to states’ respective integrity units. Those teams comb through reams of provider records and related data to uncover billing errors and overpayments.
Bill Logan, a compliance director at MaineCare, told lawmakers that the program integrity unit recovered about $1.2 million from violations last year. Those violations don’t necessarily signal fraud — the intentional act of deception — and many have been appealed.
Logan told lawmakers that the integrity unit sends between three and five fraud investigation referrals to the Healthcare Crimes Unit per year. That estimate aligns with data DHHS gave to Maine Public, covering six of the seven years Gov. Janet Mills has been in office.
Logan also noted that his office often falls out of the information loop once a fraud referral has been made.
Nevertheless, the political furor over the Gateway controversy continues to rage, drawing comparisons to another investigation involving MaineCare in 2002. Audits found that a pharmacy run by former Republican House Speaker Robert Nutting overbilled MaineCare by $3.6 million. Nutting vehemently denied the fraud allegations. An investigation and settlement lowered the amount to $1.6 million — nearly the same amount as alleged against Gateway. The state ultimately recovered $400,000.
Federal data inconclusive
Federal data of investigations, prosecutions and recoveries bring little clarity to the prevalence of MaineCare fraud or the state’s efforts to fight it.
At a glance, annual reports to the U.S. Health and Human Services Office of Inspector General from the Healthcare Crimes Unit suggest that fraud investigations have steadily declined between 2017 and 2024 with the steepest dropoffs occurring after the COVID-19 pandemic.
The unit averaged 46 fraud investigations per year between 2020 and 2024 and consistently reported among the lowest number of investigations in the country. In 2023 and 2024, for instance, only one other state reported fewer investigations than Maine’s Healthcare Crimes Unit, according to an analysis of the federal data.
Those data show more than $26 million in recoveries between 2017 and 2024.
In 2023 and 2024, the unit recovered $206,000 and $236,000 from prosecutions or civil settlements, respectively. Those recoveries represented about 13% of the federal operating grant to the 10-person Healthcare Crimes Unit. The MaineCare integrity unit made seven fraud referrals to the Healthcare Crimes Unit in 2024 and two in 2023.
A big settlement can also skew the picture when recoveries look robust. In 2020, Maine was part of a $700 million multistate settlement with the pharmaceutical company Reckitt Benckiser Group over its marketing of Suboxone. Maine’s share of the settlement was $5 million, a sum boosting more than $16 million in recoveries that year — the most between 2017 and 2024.
Similarly, in 2016 the state recovered $24.4 million, including a $7.7 million in a multistate settlement from the drug company Wyeth.
Such cases are often initiated by U.S. district attorneys in cooperation with state Medicaid Fraud Control Units like Maine’s Healthcare Crimes Unit, not referrals from states’ program integrity divisions.
According to the Kaiser Family Foundation, there is no comprehensive or reliable measurement of Medicaid fraud.
Interpreter questions
Overbilling for interpreters is at the center of the Gateway Community Services controversy. While the company has denied the allegations, the case follows two federal cases involving several Somali immigrants.
One of those cases ended in 2021 with the conviction of two men, Abdirashid Ahmed and Garat Osman, for defrauding MaineCare for interpreter services. A second, involving several defendants at the provider Bright Future Healthier You, is being prosecuted for tax fraud but also involves the alleged misuse interpreters. The Bangor Daily News recently reported that Bright Future Healthier You was the leading biller for MaineCare interpreter services over the past years. Gateway was the second largest biller.
The Bangor paper also reported that Brian Pellerin, who formerly worked for the HHS Office of Inspector General, had warned state officials in a 2020 memo about suspiciously high billings for interpreter services within MaineCare.
An official with DHHS acknowledged that interpreter services billings are a concern, but it’s unclear if that has led to greater scrutiny of such MaineCare billings. Additionally, it’s unclear whether the agency will push to restore licensing requirements for interpreters in the Maine Legislature. Those requirements were removed in 2019 in a bill framed as an overhaul of requirements for American Sign Language interpreters.
Maine Public reviewed the legislative history for that bill, but found no discussion or debate over the removal of language interpreter licensing. It passed the House and Senate without debate and “under the hammer,” meaning there were no roll call votes.
