What the report focused on was a review of the background of Medicaid providers to determine whether providers with questionable financial and criminal histories gained entry into Medicaid.
The report went further to look and see if ownership of the providers was reported and if there were any tax liens against the provider.
Needless to say, it was not pretty.
Even though there is a comprehensive plan for program integrity, let's take this time to do our own analysis of the exclusionary program.
First, the States Medicaid Director is housed in a different venue than the State Medicaid Fraud Control Unit, which removes and prevents any conflict of interests, but there exists an issue of reporting compliance.
In the arena of child welfare, there is no State provision that penalizes a State Medicaid Director for not reporting violations of law, including Medicaid fraud, to the Attorney General, who heads up the Medicaid Fraud Control Unit. Therefore, violation of the material provisions of federal or state laws would not necessitate exclusion from the Medicaid providers program.
Even if a child placing agency, as Targeted Case Management is a component of Medicaid, if noticeably found to have violated federal and/or state laws, States do not mandate the reporting to the Medicaid Fraud Control Unit.
It is the authority of the States Attorney General to prosecute and recover Medicaid fraud, but not all States have False Claims Acts, or False Claims Acts that encourage reporting from the general public or whistle blower protection from government employees.
The heaviest weighted reason there is no backgrounds for Medicaid provider eligibility or exclusionary database for child welfare providers is, under FOIA exemptions, any information dealing with a child is protected under seal. In this way, there is no possibility for verification of the criminal history and owners of the child welfare agency. Furthermore, child welfare agencies are, for the most part, non-profit, meaning they are automatically excluded from any external audit or standard review of operations.
In the event a child welfare agency was found to be ineligible as a Medicaid provider, the remedy is to reorganize under a different name, with the approval of the Attorney General, and continue to provide services.
In child welfare, it is the Attorney General who has the overseeing authority to protect children. Even though the models vary from State to State, for the most part, it is the States Attorney General who ultimately protects the contractual arms of the private and public child welfare agencies in a court of law.
Simply put, it is the obligation of the States Attorney General to represent child welfare agencies in legal matters when the issue of Medicaid fraud surfaces, and, in the same breath, it is the obligation of the States Attorney General to prosecute child welfare agencies that engage in criminal activities which would make them ineligible to be a Medicaid provider.
Unfortunately, the States Attorney Generals will neither a friend or foe be to CMS. By allowing Medicaid fraud in Child Welfare to flourish, States are not faced with the challenge of excluding providers. What we have here is a pervasive ethical issue dealing with no-bid contracts. There are no contractual debarment, license revocation, sanctions or prosecution for child welfare agencies who are found to have criminal backgrounds or engage in Medicaid fraud.
In traditional sense, there are limited child welfare service providers, as many have intertwined financial incentives and personal interests with the local and state governments. By this I mean the more children who come into care, the more Targeted Case Management funds come down, which, eventually off-sets any federal financial penalties incurred for non-compliance.
If just one child welfare agency was excluded as a Medicaid provider, it would be financially detrimental to a local child welfare system with the levels of publicity and funding opportunities.
That's the loophole, States Attorney General do not incorporate child welfare Medicaid Fraud as a legitimate component of the Medicaid Fraud Control Unit, and the States continue to tap into the uncapped Targeted Case Management reimbursement funding structures.
MEDICAID EXCLUSION PROGRAM LOOPHOLE: Nobody is excluded and the States pass Federal reviews of its child welfare systems.
Here is my solution:
If they can put us on a central registry; then I say we can put them on a central registry.
For many years the Congress of the United States has worked diligently to protect the health and welfare of the nation's elderly and poor by implementing legislation to prevent certain individuals and businesses from participating in Federally-funded health care programs. Legally Kidnapped has mandated that the health and welfare of the nation's children and families must be protected by including Child Welfare Agencies in this exclusion database. Foster Care and Adoption Agencies should be banned from entering contracts using federal funds if the bases for exclusion have been met.
Bases for exclusion include for child welfare program-related fraud, child abuse, child deaths, licensing board actions, improper and questionable claims, false reports.
The effect of not being able to participate in federally funded contracts is:
- No payment will be made by any Federal child welfare program for any items or services furnished, ordered, or prescribed by an excluded individual or entity. Federal foster care and adoption programs include Medicaid Targeted Case Management, and Social Security Title IV A, B, D, and E, Maternal and Child Health Services Block Grant (Title V), Block Grants to States for Social Services (Title XX), State Children's Health Insurance (Title XXI) and all other plans and programs that provide health benefits for foster care and adoption funded directly or indirectly by the United States.
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