DOJ: Former Connecticut Resident Pleads Guilty to Health Care Fraud Charge

• Pelphrey submitted fraudulent claims for custom breast prostheses that clients did not order, purchase, or receive.
• She is released on a $10,000 bond pending sentencing scheduled for December 29.

Jacqueline Pelphrey, formerly of Manchester, Connecticut, pleaded guilty in Hartford federal court to health care fraud after waiving her right to be indicted. She owned Women’s Health Resources, which submitted fraudulent claims to Medicaid, private insurers, and other health care benefit programs for custom breast prostheses not ordered or received by clients.

Pelphrey admitted to causing $1,299,633.10 in losses to Medicaid and other health insurance plans. She is currently released on a $10,000 bond, with sentencing set for December 29 in Bridgeport. The investigation was conducted by the U.S. Department of Health and Human Services and the FBI.

• $1,299,633.10 Losses to Medicaid and other health insurance plans
• $10,000 Bond amount
• 10 years Maximum term of imprisonment for health care fraud

• Review claims submitted by Women’s Health Resources for custom breast prostheses since August 2018.
• Screen for similar fraudulent claim typologies involving post-mastectomy items and custom prostheses.
• Monitor entities and individuals named in DOJ and National Fraud Enforcement Division announcements for ongoing investigations.

This case highlights the risks of fraudulent billing schemes targeting Medicaid and private insurers, emphasizing the need for robust controls and monitoring of claims for medical devices and prostheses. Compliance officers should be alert to patterns of claims for items not ordered or received by clients, as such schemes can result in significant financial losses and regulatory scrutiny. The DOJ’s focus on fraud enforcement underscores the importance of proactive detection and reporting of suspicious billing activities.