Maine Bill: Citizen Medicaid Fraud Busters Could Reap Cash Award

EXCEPTION & EXCLUSION TO THE FALSE CLAIMS ACT:  CHILD WELFARE

Maine Bill: Citizen Medicaid Fraud Busters Could Reap Cash Award A newly-proposed bill aims to crack down on Medicaid fraud. LD 1796 would allow citizens to sue anyone they think is defrauding the system and potentially reap a monetary reward. The federal government has had a similar law, called the False Claims Act, on the books for years, as do other states. The backers of Maine's bill say it's time to get on board, and there would be safeguards to prevent abuse.

Related Media Maine Bill: Citizen Medicaid Fraud Busters Could  Originally Aired: 2/7/2012 5:30 PM  Duration: 2:39

It's unclear how much money Maine loses each year to Medicaid fraud, but nationally, the estimate is in the billions. Maine has a crime unit dedicated to Medicaid fraud. But Jeff Gifford, a Republican from Lincoln who sponsored the bill, says they've got their hands full. "I think they're overworked and under-staffed, and you've got citizens out there that know that things are going on," Gifford says. Gifford says for years he's heard his constituents complain about abuse in the system, and his bill would allow them to take action against other individuals, as well as Medicaid providers. But filing a claim with the court would be no small undertaking. Between waiting for the state to decide whether to join the suit and various legal proceedings, it can take years to see a suit to its end, not to mention the cost to file possible legal fees. That's why there's a monetary reward if a suit is successful--from $5,000 to $10,000. Robyn Merrill is a policy analyst with Maine Equal Justice Partners, a group that advocates for low-income Mainers, and who supports the bill. She says the process of filing a suit in and of itself acts as a deterrent against frivolous claims. "It's not going to hold up in court if it's just you suspect that your neighbor might be doing this," she says. "I mean, if you're going to have a case with merit that has any chance of being successful, then you're going to need some sort of evidence, some source of knowledge that you possess, that helps to demonstrate that there is indeed fraud." Most likely, says Merrill, these suits will come from people who work within a company that is engaged in fraudulent activities--the equivalent of whistle-blowers. Merrill says contrary to popular opinion, providers are responsible for most welfare fraud cases. Still, she says the bill should include some safeguards against frivolous claims, such as requiring anyone who comes forward with one to be responsible for any associated costs. And while she supports the legislation she does not think it should be limited to Medicaid fraud. "And I would submit, why not? Why exclude ourselves to Medicaid? It's certainly not like that's the only area where fraud exists," she says. Merrill says 28 states have acts that cover any fraud, including things like banking and securities. "You know, in other states where they've had this law, it's really kind of helped people to bring these things into the light of day and then also to help the states to recover the funds that they've lost through fraud." For example, pharmaceutical company Merk recently settled a suit under Massachusetts' False Claims Act. It's going to pay the state $24-million dollars for price-gouging on Medicaid drugs. Merrill says another improvement she'd like to see could prove even more lucrative for the state. She says if the language of the bill is changed to reflect what's in the federal law, Maine would receive 10 percent more in recovery funds for every successful lawsuit. The bill is scheduled for a public hearing later this month.