This is my comment to the following article which will probably not be approved by the moderator, as usual:
Medicaid fraud needs to be classified as domestic economic terrorism as the problem is pandemic in all States within its child welfare contracts and services. A Medicaid Fraud Control Unit has never been granted the power to investigate itself as the unit is housed in the Office of the Attorney General. For the purposes of child welfare, this would mean the AG would have to defend the child welfare agency that generated false claims for reimbursement of Medicaid funded foster care programs as the AG oversees the prosecution of a child abuse and neglect case that was filed in the court through another layer of fraudulently generated documentation to the court. These practices are just a few examples of the Medicaid fraud in child welfare. Nationally, the estimated amounts of Medicaid fraud in child welfare reaches into the billions. The real problem is the fact no one is willing to talk about it, except for me.
State looking out for Medicaid fraud
CHEYENNE -- Each year in Wyoming, taxpayers lose millions of dollars due to fraudulent Medicaid claims, officials say.Wyoming loses at least $15M every year.
It is estimated that Wyoming’s system loses at least $15 million each year, said Christine Stickley, director of the Medicaid Fraud Control Unit in the state Attorney General’s Office.
Medicaid is a government-funded health insurance program for people with low incomes or disabilities.
Stickley’s office investigates and prosecutes cases of fraud perpetrated by doctors and other health-care providers.
A separate office in the Wyoming Department of Family Services looks into fraud committed by recipients.
Some officials say there should be more screening in place to prevent fraud, but the Wyoming Department of Health, which administers Medicaid, says steps are taken to prevent theft.
About 69,000 people a month are on Medicaid in Wyoming. The program has an annual budget in Wyoming of more than $600 million, which includes state and federal funds.
Doctors who steal
Stickley’s office investigated a Rawlins dentist for charging for services that were not delivered.
The dentist would put a filling on only one tooth surface but bill Medicaid for three or four.
“He performed a service, but he billed (Medicaid) for a service that cost more money,” Stickley said.
In another instance, a dentist put silver fillings in but charged for the more expensive tooth-colored caps.
The U.S. Attorney’s Office prosecuted that case, and the dentist was found guilty of felony theft or embezzlement in connection with a health-care benefit program.
The dentist had to pay $51,000 in restitution, and his license was suspended for two years.
Stickley said there also was a recent case in which a Cheyenne optometrist allegedly disregarded Medicaid billing rules.
That could not be proven as outright fraud, she said, but Medicaid still recovered the funds in civil court through the federal False Claims Act.
That allowed the state to collect two and a half times the amount of money that was improperly billed. In the end, the optometrist paid a total of $250,000 to Medicaid, Medicare and TRICARE.
Medicaid funds that are recovered are split between the state and federal government to go back into the system, Stickley said.
There have been some years in which her office netted more than $2 million, but that was partly due to national cases involving pharmaceutical companies.
Her office can only take up cases based on referrals, she said.
Stickley’s office also looks into cases of abuse and neglect and misappropriation of funds in Medicaid-funded nursing homes.
Her office collected $679,648 in misspent Medicaid funds last year, and it investigates about 45 to 55 cases a year.
Records are vital
Sometimes a case hinges on records, which Medicaid requires doctors to keep for six years.
But Stickley said providers who commit fraud may not keep them because they would prove their actions.
The dentist that her office prosecuted destroyed and altered records, she said.
“We find very often that people don’t have records,” she said.
But in the case of the dentist, the fraud was proven by having another doctor look into the children’s mouths to see the work that was actually done versus what the doctor billed Medicaid.
“When people don’t keep records, that’s a red flag to us,” Stickley said.
A bill that failed in this year’s legislative session would have made it a crime for Medicaid service providers to not maintain records in accordance with the federal rules.
Patients, too
Another type of Medicaid fraud involves patients lying to get government-funded health care.
Those crimes are investigated by the Fraud & Recovery Unit in the Wyoming Department of Family Services.
“There are watchdogs out there,” said Nanette Vasey, manger of the unit.
The office is currently handling about 255 “overpayment cases,” but not all of them constitute fraud.
Added Michele Rossetti, fraud and recovery supervisor, “If someone receives a benefit that they were not entitled to, then we establish an overpayment and then we have to collect on that. We try to get that money back.”
Of the 255 cases, 39 of them are fraud or there is evidence of fraud, she added.
The rest of the cases could be issues such as paperwork errors.
“They weren’t trying to do anything on purpose to try to get a benefit,” Rossetti said. “It was just an inadvertent household error.”
The office is trying to collect about $1.7 million in overpayments.
Vasey said she is frustrated with the lack of punishment given to some people who commit Medicaid fraud. She said her office’s federal partner, the Centers for Medicare & Medicaid Services, does not offer a lot to the states to use.
Rossetti added, “We are adamant in working with the prosecutors to at least get the restitution ordered. We do know there are times when the recipient will not be able to pay the monies back because it’s so high, but we want the order.”
If people are sentenced to prison for Medicaid fraud, it’s usually because they are already on probation for another crime, Rossetti said.
Another area where there is a lot of Medicaid fraud is in nursing homes, Vasey said, adding that in those cases it is not the patient committing the fraudulent act.
“It is people acting on behalf of a person in a nursing home,” Vasey said. “Often, family members do not report true assets of these folks. They get pretty greedy real fast. It’s pretty sad.”
Sometimes people turn down insurance from their employers so they can bring home more in their paychecks. And when they have medical programs, they fall back on Medicaid.
“A lot of these people have adequate income,” Vasey said.
Other times people will submit an application, and it shows that they have too much income. Then the person will submit another application shortly after with an income removed so they will qualify.
Rossetti said she thinks Medicaid fraud is getting worse because of the “grapevine” in which people learn from others how the system can be defrauded.
The recipient fraud office has four investigators for the state, down from the six it had a few years ago before state and national budget problems.
Between July 2010 and June 2011, the office handled 609 investigations of public assistance fraud, which included Medicaid and other programs.
Bill failed
A bill that supporters said could have helped Wyoming recover more Medicaid fraud failed this year.
State Sen. R. Ray Peterson, R-Cowley, who sponsored it, said it could have possibly doubled or tripled the amount of Medicaid fraud that the state recovers.
It would have created a state false claims act that would have allowed Stickley’s office to pursue Medicaid fraud in civil court.
Currently, the state can only pursue Medicaid fraud cases criminally.
A state civil process could result in more fraudulent funds being collected because the burden of proof in civil court is not as high as a criminal court, Stickley said.
If the state wants to pursue Medicaid fraud in civil court, it has to go through the federal government.
And sometimes the U.S. Attorney’s Office may not have the time to deal with some of the state’s smaller Medicaid fraud cases.
The state needs to do more when it comes to pursuing suspicious Medicaid claims, Peterson said, adding that it is only collecting a small amount of the fraud.
If the fraudulent money is not recovered and put back into the system, it could mean funding from highways, libraries and schools would have to be used to restore Medicaid, he said.
“I look at it as my tax dollars and your tax dollars,” Peterson said. “It’s millions and millions of dollars.”
More screening?
One aspect of Medicaid for family and children is that it is based on “self-declaration” of income, which means the information is not verified up front.
“As a taxpayer you’re going to be horrified with this,” Vasey said. “For most programs when you apply you are required to bring in verification of various eligibility issues, such as verification of your income.”
Medicaid is “a little more prone to fraudulent activity,” she added.
Self-declaration is in place to “remove some of the barriers that kept people from applying,” state Department of Health Medicaid eligibility manager Jan Stall said.
But she added there are still programs in place to catch fraud.
She said Medicaid reviews a random sample of cases every three years to ensure the people getting benefits are eligible.
And she said there is a Medicaid quality control program that determines if the eligibility was determined correctly.
Stall said the state cannot do any more to verify income because it is prohibited by the Affordable Care Act passed by Congress in 2010.
Under the act, the state would lose its federal Medicaid funding if it added more eligibility screening, she said.
Federal funds make up half of the state’s Medicaid budget, she said.
But she said new systems are coming online to hold down fraud and eligibility errors.
The federal government is setting up a “data hub” that states can connect to in order to verify income and citizenship.
The state’s new system has to be in place by Jan. 1, 2014, to coincide with the implementation of the expansion of Medicaid.
The expansion will mean about 30,000 more people in Wyoming will be eligible for Medicaid.
The federal government will pay all of the costs for the newly eligible members for the first two or three years. But the state will cover 10 percent of the new members’ costs by 2019.
Losses disputed
Stall said the estimate of at least $15 million lost to Medicaid fraud each year in Wyoming sounds high.
She said a random sampling of Medicaid cases a few years ago found little fraud. She added that there are some cases of mistakes made on applications, but little fraud.
“The quality control measures and programs we have do not indicate that we have a significant amount of Medicaid fraud in Wyoming,” Stall said.
She noted that a random sample of statewide Medicaid cases showed about a 5.7 percent error rate in terms of inaccurate eligibility determinations.
It could be that some people just didn’t understand an application question, Stall said. And there could be times when a Medicaid eligibility worker makes an error.
“That is in no way all fraudulent activity,” she said.
