State looking out for Medicaid fraud

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.

New York Medicaid Fraud Highlights and Criminal Liability

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New York Medicaid Fraud Highlights and Criminal Liability

Posted on Tue, May 06, 2008

Picture this: you're a health care provider. Your business largely depends on Medicaid billing. In fact, Medicaid pays your bills. Your business is booming and then one day you get a letter or a call from The Office of Medicaid Management or an Attorney General's Office. They tell you they investigate certain claims made by your office. They ask you for your billing records and your mood suddenly is not the same it was 5 minutes ago. Assuming the investigators have reasons not be impressed with your Medicaid billing practices, you will need a lot of hope and maybe some serious help because serious trouble is probably on the way. 

New York's Medicaid program has been funded more than 40 years ago and what it presently is may be defined as a cash cow or a "honey jar" that attracts all kinds of money-loving bees. New York Medicaid enrolls millions of people and spends over $40 billion a year for everything from medical care to transportation to adult daycare to paying for shoes, diapers, etc. Because may Medicaid programs were so easy to exploit, New York Medicaid fraud became quite rampant and uncontrollable. It became an industry in itself and fortunes were made on Medicaid Fraud. 

There are several ways in which Medicaid Fraud can occur. The most popular method of Medicaid fraud with which defense attorneys routinely deal is billing for services that were not provided. In fact, some providers manage to bill millions of dollars in fees for services they have never performed. The next forerunner is double billing (billing Medicaid after private insurance and/or the recipient have already paid for services). Unnecessary procedures and appointments billed to Medicaid are popular, too. 

Many providers find themselves in hot water because they have unlicensed personnel perform services that may only be provided by licensed persons as per Medicaid regulations and bill Medicaid as if the professional do the work. Health care providers routinely overcharge Medicaid by inflating time they actually spend on providing their services. 

On occasions, providers engage in fees sharing with other provider. This means referring patients to other offices that bill Medicaid and share the reimbursement paid by the Medicaid program.

Among New York Medicaid Providers involved with New York Medicaid Fraud are medical and dental offices, "ambulette" transportation companies, hospitals, nursing homes, pharmacies, school districts officials, and even retailers. 

New York Medicaid Fraud cases may be investigated by the Office of Medicaid Management, the Office of the Attorney General, the local law enforcement, or even federal investigators. Because the problem has gotten out of hands lately, Attorney General Cuomo and the local district attorneys are really cracking down on New York Medicaid Fraud. According to the April 30, 2008 Attorney General Office's report, New York had recover $112,5 millions in Medicaid fraud recoveries in 2007. 

The latest in the string of New York Medicaid Fraud indictments is the prosecution of B&H Health Care Services, Inc., (Nursing Personnel Home Care), a Licensed Home Care Service Agency and half a dozen of its shareholders and managers who managed to bill over $30 million in Medicaid fees. 

Providers accused of New York Medicaid Fraud face various fraud-related charges as well as civil suites claiming damages. In the case of B&H Health Care Services, for example, the indictment contains charges of Grand Larceny in the First Degree (a Class B felony that carries a mandatory minimum sentence of 1 year and a maximum sentence of 25 years' imprisonment) and charges of Offering a False Instrument for Filing in the First Degree (a Class E felony that carries a maximum sentence of 4 years' imprisonment.) The civil suite filed by the state demands treble damages of $90 million. 

If it is a federal investigation, charges and potential consequences, both criminal and financial, could be even more severe.

So, let's go back to the beginning. You get that letter or a phone call. Your next steps are limited to telling the investigators to disappear from your life, telling them all they want to hear, or telling them that your lawyer will contact them for you. Let me end with a banality: if you are accused or investigated for Medicaid Fraud, it is not the time to do it yourself.

HHS Medicaid Fraud Control Units 2016 Annual Report & Me

When dealing with Medicaid Fraud in Child Welfare, the Medicaid Fraud Control Units are useless,

pursuant to statutory authority.

Yes, that is correct, Mediciad Fraud in Child Welfare is the biggest racket where one is, guaranteed, never to be criminally prosecuted, nor civilly penalized, because, it is all in the best interests of the child.

Let us examine the Michigan.

Rumor has it Michigan is so jacked up when going after Medicaid Fraud, that the U.S. DOJ and OIG HHS have teamed up to use the state as an example of "what not to do" when going after Medicaid Fraud.

A few years ago  I had FOIA'd for its mandated annual report to the OIG.  They told me they did not have one.

Seriously.

Then, this one time I had to call the U.S. OIG HHS to let them know that they had substantial errors in its review of Michigan's False Claims Act.  At least they thanked me.

So, for your reading pleasure in learning about MFCUs, allow me to do what I do best, in fuchsia.

Transcript for audio podcast: Medicaid Fraud Control Units

[Don White] What role does OIG play with State Medicaid Fraud Control Units and why are they important? I'm Don White in public affairs with the Office of Inspector General, and today, we're here with Richard Stern, OIG's director of program oversight for the Medicaid Fraud Units, and from our regional Office of Investigations, Special Agent in Charge Shimon Richmond of the Miami region. Shimon, what is a MFCU?

Greetings Don, Richard and Shimon.  I am here to bring jolly into your professional lives and do something about Medicaid Fraud in Child Welfare.

[Shimon Richmond] Well, Don, aside from being an awkward acronym, MFCUs are Medicaid Fraud Control Units. And as that name suggests, they investigate and prosecute Medicaid provider fraud, as well as patient abuse and neglect in health care facilities. They are state-based agencies and there is one of each in 49 states and the District of Columbia.

Well, Gentlemen, you failed to state that the States MFCU were never designed to go after Medicaid Fraud in Child Welfare, and have yet, to the date of this post, publicly addressed the fact that child welfare programs of the Adoption Safe Families Act were enshrined by the Congress to be impervious to any form of external scrutiny of its operations through IRS non-profit certifications.

[Don White] Well Richard, so you understand this best, why do we need Medicaid Fraud Control Units anyway?

[Richard Stern] Well, while we hear a lot about Medicare Fraud, involving the program for the elderly and the disabled, total taxpayer costs are actually higher in Medicaid, than in Medicare, with total yearly expenditures for Medicaid of over $500 billion dollars. And fighting fraud in Medicaid can be especially challenging. Each state runs its own program, So the rules vary from state to state. And we don't have good data at the national level. As we often hear, once you've seen one Medicaid program, you've seen one Medicaid program.

Guys, you failed to mention that child welfare programming, now, almost completely privatized, is untouchable when it comes to its state operations.  See, child welfare so-called oversight has been placed in the make shift huts called ombudsman offices, due to the fact that the original statute for the creation of MFCUs was exclusively designed for the aged.

Ombudsman offices of the States are then, on a secondary level, with watered down oversight authority of referral to law enforcement, further constrained due to privacy laws.  This means that there are no mandates for the States to adopt any policies for mandatory referral of suspected Medicaid Fraud in Child Welfare, to the State Attorneys General for prosecution, recovery, sanctions, exclusions, contractual debarment or criminal prosecution.

Why, you may ask?  Well, boys, the reason is two-fold.  First, you cannot audit God, meaning, any IRS charity/non-profit cannot be audited.  Secondly, anything dealing with child welfare is exempted and excluded from FOIA, as well as any other public disclosure, in the best interests of the child, you know.

[Don White] I understand that MFCUs have an important role in investigating and prosecuting patient abuse and neglect in nursing homes and other health care facilities as well, is that true?

[Richard Stern] Yes, that is true.

Richard, I understand that MFCUs do not do a damn thing about children being legally kidnapped by Child Protective Services, being drugged, raped, beaten and tortured in foster care, where each and everyone of these activities are cost-reimbursed through Medicaid.

[Don White] I can see that investigating Medicaid fraud would certainly be challenging given how different each State's programs can be. So since fighting Medicaid fraud is an OIG priority and a Top Management Challenge for the U.S. Department of Health and Human Services, I'm wondering how OIG works with these State MFCUs? Richard?

The OIG does absolutely nothing to work with the States MFCUs because the administrators of the HHS Children and Families Administration are the same people who were running these fraudulent child welfare programs, grant research and are, also, lobbyists.

I would be so remiss not to mention that the legislators benefit from the campaign contributions from the booty of Medicaid Fraud in Child Welfare to keep the same lack luster culture in place of willful ignorance to the blatant defalcation through double billing and phantom billing.

[Richard Stern] Well, yeah. Well, OIG administers a grant to each of the units that provides 75% of their funding. We also set performance standards, we review each state's program, we provide technical assistance identify best practices, and we collect and analyze statistics that we make available to the public on OIG website.

And you still fail to acknowledge that Medicaid Fraud in Child Welfare is an intentionally omitted variable in the annual report, I have so graciously provided, below.

Here are the data for FY 2016 Medicaid Fraud in Child Welfare prosecuted and recovered through the States MFCUs: 99 - missing data; $0.00

[Don White] How does that grant program work, Richard?

[Richard Stern] Well, as part of the Medicaid program, each of the States is required to have a MFCU or to receive a waiver. And the way it works, in exchange for receiving Federal matching funds, the States run a self-contained unit that includes investigators, auditors, and prosecutors or other attorneys. This model of having prosecutors work side by side with investigators and auditors has proven to be very successful. Most of the units are in the State Attorney General's Office and either prosecute cases themselves or refers cases to other State, County, or Federal prosecutors. MFCUs also collaborate closely with their State Medicaid programs, the OIG Office of Investigations and the FBI, as well as Department of Justice and U.S. Attorney offices nationwide.

Hold on a minute.  Let me put my 2 cents in about those waivers.  Those waivers created another quagmire when it comes to conflicts of interests, but let us start with the States Attorney General.  

How is it the States Attorney General can prosecute contractual entities it contemporaneously advocates, while prosecuting cases in child welfare proceedings?  See, it is like this.  The state contracts privately with a child placing agency to provide Targeted Case Management services to a foster child.  The agency proceeds to submit fraudulent Medicaid billing for cost reimbursement and uses those exact same need for services as legal standing to proceed with termination of parental rights, which is litigated by the States Attorney General.  

So, what some states did was to accept the waiver and house its MFCUs in places other than the AG, even though there are only a few states which have done this.  Placement of its MFCUs are then ensconced deep within the same agency which reimburses Medicaid costs.  Yes, this is an inherent conflict of interest but, under ASFA, there is a "right to lie" when submitting the false claims of Medicaid cost reimbursements in child welfare.

To top all this off was another set of Medicaid waivers in child welfare.  These waivers allowed States to use Targeted Case Management funding for what they attempted to coin as "home-based/community-based" services under family preservation.

[Don White] But I'm wondering how successful have these MFCUs been when working with OIG in fighting Medicaid fraud?

I am going to go out on a limb and say that these MFCUs have not been very successful when working with OIG in fighting Medicaid fraud because Medicaid fraud is a major funding mechanism when it comes to human trafficking.  Oh, you do know human trafficking is exactly what child welfare is, right?  Right?  I'll let Shimon answer that.

[Richard Stern] I'll let Shimon answer that. Florida, and especially South Florida, is one of our hot-spots for health care fraud.

[Shimon Richmond] Sure thing. So around the country, the OIG works a lot of cases with the Medicaid Fraud Control Units. In 2016, our Medicaid cases resulted in 312 indictments, 348 criminal actions, and 222 civil actions. These Medicaid cases - some of which also involved Medicare - resulted in almost $3 billion dollars in expected recoveries.

Shimon, you did not answer how successful the OIG has been in working with MCFUs in stopping Medicaid Fraud in Child Welfare and its human trafficking.  Around the country, Child Protective Services targets populations for Medicaid fraud billing opportunities through Targeted Case Management.

[Don White] So how important would you say these Medicaid Fraud Units are to your operations, Shimon?

[Shimon Richmond] Well Don, they're absolutely critical to our efforts.

So, what exactly are your efforts to stop Medicaid Fraud in Child Welfare?

[Don White] Can you give us some recent examples where your people worked with the MFCUs?

Hello?  Can someone please answer my question as to what are your efforts to stop Medicaid Fraud in Child Welfare?

[Shimon Richmond] Sure Don, we work with the Florida MFCU quite a bit. And there are several cases that come immediately to mind. First, working with the Florida MFCU, we charged 10 owners of a Miami-Dade county Assisted Living Facility with health care fraud and receiving illegal cash kickbacks in return for referring residents to a specific pharmacy. The pharmacy owner was sentenced not long ago, to federal prison and ordered to pay back more than a million dollars to the Florida Medicaid program. This ring was exposed by joint efforts between OIG agents and MFCU agents working in undercover capacity.

Have you guys ever hear of the Medicaid defalcation stories in residential institutions through what I like to call kiddie kickbacks?

[Richard Stern] You know I should also say, however, the MFCUs work many of their own cases without assistance from other agencies, and do so very successfully. MFCUs investigate, and prosecute, patient abuse or neglect in nursing homes, and hospitals, as well as in assisted living facilities. Sadly, the abuse of the elderly and other residents of these facilities has become a major social issue. These are difficult cases, and MFCUs are one of the few State or Federal agencies devoted to criminal prosecution of patient abuse or neglect.

Well, boys, if MFCUs can work on their own cases without assistance from other agencies, that would mean that the Unit would end up prosecuting its state attorney general by accessing information of child welfare cases without authorization, contaminating any evidence, leaving the state contractual entities to continue to fraudulently bill Medicaid.

[Don White] Well, Shimon, could these Medicaid Fraud Control Units be doing even more?

Let me answer that for you, Shimon.  Yes.  These Medicaid Fraud Control Units can be going after Medicaid Fraud in Child Welfare by starting with a public admission that it needs congressional help in implementing parallel jurisprudence and civil rights in child welfare.

[Shimon Richmond] Absolutely they could. But many of the MFCUs really need additional resources to fight the fraud in their jurisdiction. And currently there are no MFCUs in Puerto Rico or North Dakota. Also, the Medicaid Fraud Control Units need the legal authority to investigate and prosecute patient abuse or neglect in home- or community-based settings in addition to institutions. The current rules made some sense when Medicaid services were primarily provided in institution in times past, but as those services are increasingly provided in the home and the community, things really have changed.

Hey, I have a better idea and it will not cost as much.  How about setting up a bounty program?  I am not speaking upon the False Claims Act, as the victims of Medicaid Fraud in Child Welfare are, meeting the criteria of Title IV-A, are in the exclusive category of "The Poors".  No money, no justice.

So, instead of an impossible qui tam, how about an administrative program like the IRS Whistleblower program?  Yes, it will take time, but you will be doing "hands-free" data collection on Medicaid Fraud in Child Welfare, then, can run those data with program performance, well, let us just say the possibilities are endless.

[Richard Stern] Right. We will need Federal legislation to make that happen and there does seem to be interest for that happen on Capitol Hill.

I just told you guys that Medicaid Fraud in Child Welfare funds their political campaigns, so, of course, there is no interests on Capitol Hill, nor the White House.

[Don White] Well, I hope that this podcast has provided some helpful information on the important work by of the Medicaid Fraud Control Units.

And I hope that I have provided some helpful information on the important work the Medicaid Fraud Control Units do not do.

[Richard Stern] Thank you for the opportunity to speak about the work of the over 1900 MFCU professionals across the nation.

I would like to thank everyone who has taken the time to find out more on Medicaid Fraud in Child Welfare and the constraints of the States Medicaid Fraud Control Units.  Remember to sign up for your daily dose of me!

[Don White] Any last words, Shimon?

[Shimon Richmond] Well, just that the MFCU's play a critical role in protecting the taxpayers and the residents of health care institutions, so I'm happy to participate and glad that we can discuss this today.

[Don White] Thanks a lot.

Thank you, gentlemen, for allowing me the opportunity for another glorious castigation on the DOJ's and HHS' complete and utter failure to end Medicaid Fraud in Child Welfare.

On of these days, the world will finally listen to me.

Medicaid Fraud Control Units Statistical Chart 2016 by Beverly Tran on Scribd

Voting is beautiful, be beautiful ~ vote.©

North Carolina Medicaid Swat Team

Governor Beverly Perdue of North Carolina has teamed up with her Attorney General to create a Medicaid Swat Team.

North Carolina began the creation of this action by including TRICARE in an investigation of child welfare fraud. This, still to this day, is the only instance where child welfare fraud was examined from the direction of military health care.

I can only speculate (until I call the Attorney General) that is this Medicaid Swat Team is a product of the Medicaid Fraud Control Unit.

Since North Carolina is being such a progressive state in attacking Medicaid fraud (unlike Michigan), I am willing to put some money down that the state will develop the very first model to approach child welfare fraud from inside the structures of government. (I have the other models.)

All I can say is, thank you Governor Perdue, but I am still in love with Roy Cooper.

Gov. Perdue Kicks Off Campaign to Crack Down on Medicaid Fraud, Waste and Abuse

Posted on April 14, 2010. Filed under: North Carolina Medicaid | Tags: Medical practice insurance audit, NC Medicaid, NC Medicaid Audits, NC Medicaid MIC, North Carolina Medicaid Integrity Contractor |

Gov. Bev Perdue today announced a series of aggressive measures to set government straight by cracking down on Medicaid fraud, waste and abuse that costs taxpayers millions of dollars each year. The steps include stronger investigation and prosecution of potential abusers, including new Medicaid SWAT teams, better use of technology to detect and prevent abuse, and a campaign to encourage the public and providers to report suspected abuse.

“In these tough times, when Medicaid enrollment is growing even as we face deep budget shortfalls, we must do more to root out waste and crack down on folks who are abusing or defrauding Medicaid,” said Perdue. “Tens of millions of taxpayer dollars each year are wasted on Medicaid fraud, waste and abuse. It’s got to stop and we will not allow it to continue.”

A new software system in DHHS will bring the detection of potential Medicaid fraud into the 21st century, by quickly analyzing thousands of Medicaid claims and flagging suspicious cases. Once identified, the most egregious cases will go to newly created Medicaid SWAT teams, specially trained investigators who will quickly deploy to investigate providers or consumers identified as potential abusers of the system.

Gov. Perdue also called for toughening North Carolina’s anti-fraud laws by stopping kickbacks to providers that refer patients for Medicaid services and ending the practice of soliciting patients for services they don’t need.

Gov. Perdue announced these new initiatives at a press conference at Rex Hospital in Raleigh. She also called for doubling the staff size of the Attorney General’s Medicaid Investigations Unit and an aggressive awareness campaign to encourage individuals and providers to report Medicaid fraud, waste and abuse when they suspect it.

“Medicaid fraud hurts our state’s most vulnerable residents and robs taxpayers,” said Attorney General Roy Cooper, whose Medicaid Investigations Unit handles criminal and civil cases. “Adding more investigators and ways to detect fraud is the right direction to go to stop those who abuse the system.”

The Attorney General’s Medicaid Investigations Unit is composed of investigators, auditors, attorneys and State Bureau of Investigation agents who look into cases of fraud, abuse and neglect of residents in medical facilities that receive Medicaid funding. Proceeds from civil settlements typically reimburse Medicaid and penalties go to North Carolina public schools. Last year, the unit recovered $52 million, with a 10-year total of more than $300 million recovered.

Nothing Quick & Dirty in Florida Healthcare Fraud Summit

For viewing pleasure, I shall go through this press release and identify the limitations of using data mining for the purposes of detection and preventing Medicaid fraud in child welfare in red.

HHS Announces New Tool to Help Fight Health Care Fraud in Florida

HHS Secretary Sebelius and Attorney General Holder to Co-Host Fraud Prevention Summit Tomorrow in Miami

U.S. Health and Human Services Secretary Kathleen Sebelius announced today that health care fraud fighters in the state of Florida will now have additional funding to help find potential fraud and abuse in the state’s Medicaid program through the use of Medicaid claims data.

The health care fraud fighters in Florida who are versed in the area of Medicaid fraud in child welfare, including those who are willing to import this expertise to the state, are typically grassroots organizations and lone parents whose parental rights have been terminated who have been made out to be dismissed on their cries of fraud in child welfare.  Lacking the sophistication to participate in qualification of this additional funding, Medicaid fraud in child welfare will continue along its happy incremental increase slope.

Today, Secretary Sebelius approved Florida’s Medicaid waiver request to help fund a demonstration program that will allow the state’s Medicaid Fraud Control Unit (MFCU) to “mine” Medicaid Management Information System (MMIS) data to identify cases of potential Medicaid fraud.

The MFCU will rely upon subcontracting this data mining demonstration program to Maximus, Inc.   With a reputation of being the "jeepers-creepers keeper" of the record, Maximus, Inc. does not have a very reliable track record when it come to skills, knowledge and abilities (I refer to as the "skas") when it comes to handling data.

Corporate Integrity Agreement between the HHS OIG and Maximus, Inc. 2007  

Medicaid billing for many health care services in South Florida is disproportionately high compared to other parts of the country. Although significant progress has been made, fraudulent billing health care fraud continues to cost Medicaid millions of dollars.

Medicaid billing in child welfare for the state is proportional to the other States as the pattern exists in every state.  Very little progress has been made in Florida regarding the aberrant billing practices in child welfare fraud which continues to cost Medicaid billions of dollars. 

“To fight health care fraud, we need to coordinate all of the resources and data we can muster,” said Secretary Sebelius. “By allowing the state of Florida to use more information to find potential fraud in Medicaid, this waiver will improve Florida’s ability to effectively identify and combat fraud and abuse.”

There is a reason why there will never be a coordination of resources and data to end Medicaid fraud in child welfare because the child abuse propaganda marches to the tune of the imperialistic morality parade.

The announcement comes in advance of the Department of Health and Human Services and Department of Justice’s first Regional Health Care Fraud Prevention Summit being held tomorrow at the Knight Center in Miami, Fla.

The summit, which will feature keynotes remarks by U.S. Attorney General Eric Holder and Secretary Sebelius, kicks off the first in a series of day-long summits bringing together a wide array of federal, state, and local partners, beneficiaries, providers, and other interested parties to discuss innovative ways to eliminate fraud within the U.S. health care system.

As part of its efforts to coordinate the fight against fraud across the nation’s health care systems, including Medicaid and Medicare, data mining will allow Florida’s MFCU to sort electronic claims through the use of statistical models and intelligent technologies to uncover patterns and relationships. Using the identified patterns, investigators can review Medicaid claims activity and history to find abusive or abnormal use of services and billing that may be potentially fraudulent. Data mining is done with software programs which include algorithms that automatically analyze the MMIS data.

The HHS Inspector General reported to Congress just a few months ago that the MMIS data were not "timely, accurate, or comprehensive for detection of fraud, waste, and abuse."  The MMIS data, handled by the unenlightened over at Maximus, Inc. is not the only database Florida has to execute the task of ending Medicaid fraud in child welfare.

There are other statistical methodologies that can easily be applied to detect patterns and relationships of fraud in child welfare.  There are other databases and potential other databases that can be analyzed but will never see the light of day.   

There is no oversight and no reporting avenues for fraud in child welfare.   There is no exclusionary database in child welfare.

Currently, state MFCUs are prohibited from using federal Medicaid matching funds to detect potential fraud through routine claims review procedures such as screening of claims, analysis of billing practice patterns, or routinely verifying that billed services were actually received by patients, since these functions are a primary program operation function of the state Medicaid agency. Instead, MFCUs generally rely on referrals from the State Medicaid agency. The waiver approved today will allow the Florida MFCU to use federal matching funds to apply sophisticated electronic data mining tools that are beyond the scope of the claims review activities normally performed by the State Medicaid agency to identify potential fraud.

Currently, the MFCU is prohibited from ending Medicaid fraud in child welfare.  The MFCU is located in the Office of the Attorney General.  The Attorney General represents state agencies in dealing with child welfare.  There exists an inherent conflict of interests for the MFCU to prosecute and recover Medicaid fraud in child welfare as it is the entity which defends the actions of the state agencies that have committed Medicaid fraud in child welfare.

In addition, there was nothing written in the final rules mandating MFCUs to address Medicaid fraud in child welfare.  The final rules exclusively were designed to address the aged and "safe harbors", exceptions to fraud practices.

The Centers for Medicare & Medicaid Services (CMS) expects the MFCU to work closely with AHCA to ensure their collective efforts are effective. CMS will monitor the progress of this waiver in conjunction with the HHS Office of Inspector General, which has oversight of MFCUs.

CMS should expect to work closely with the people to ensure there collective efforts to end Medicaid fraud in child welfare will take effect, otherwise, Medicaid fraud (as well as all other frauds) in child welfare will only be addressed under the False Claims Act.  Unfortunately, there are very few law firms that are willing to grasp the concept that fraud in child welfare even exists.

“The demonstration approved today will allow Florida’s Medicaid Fraud Control Unit to take full advantage of their expertise in detecting and investigating Medicaid fraud,” said CMS Administrator Don Berwick, M.D. 

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How To Catch A Medicaid Fraudfeasor: A Primer

As those of you loyal followers who may already know, and for those who wish to learn,
The U.S. Department of Health and Human Services Office of Inspector General (DHHS OIG) in partnership with the U.S. Department of Justice Attorney General (DOJ AG) has created the Health Care Fraud Enforcement Task Force (H.E.A.T.) to stop Medicare and Medicaid Fraud.

The purpose of H.E.A.T. is to end the annual billions of dollars in fraud, waste and abuse of taxpayer dollars, because, obviously, the states Medicaid Fraud Control Units just were not doing what they were suppose to be doing, and that is stopping Medicare and Medicaid Fraud.

In addition, it seems that the DHHS OIG and the DOJ AG have publicly confessed, with its creation of H.E.A.T., to have been snoring and drooling at the helm as the overseeing admirals of the states Medicaid Fraud Control Units.

But now, since the act of contrition, we need to move forward and get these Strike Forces up and operating, quickly!

Below, is the precursor of my primer on "How To Catch a Medicaid Fraudfeasor."
(Fraudfeasor means simply, "One who commits fraud.")

The following is taken directly from the National Association of Medicaid Fraud Control Units Frequently Asked Questions:

1. What is a Medicaid Fraud Control Unit?

A Medicaid Fraud Control Unit (“Unit” or “MFCU”) is a single identifiable entity of state government, annually certified by the Secretary of the U.S. Department of Health and Human Services. The Unit has either statewide criminal prosecution authority or formal procedures for referring cases to local prosecutorial authorities with respect to the detection, investigation and prosecution of suspected criminal violations of the Medicaid program. See 42 U.S.C. §1396b(q). There are 50 state MFCUs. 43 are currently located in the office of the state Attorney General. Connecticut, D.C., Georgia, Illinois, Iowa, Tennessee and West Virginia have Units which are in other departments of state government. North Dakota received a waiver from the federal government and does not have a Unit.

Since I enjoy using Michigan as my case study, let us begin to examine the deficiencies in this description.

Michigan has a Medicaid Fraud Unit located in the Office of Attorney General, Child and Family Services Bureau, called the Health Care Fraud Division. The duties and responsibilities are to the Department of Human Services through "Medicaid fraud and patient abuse investigations, prosecutions, civil Medicaid recoveries, and vulnerable adult matters."

What is wrong with this picture? The Health Care Fraud Division does not touch "child matters." So, why is this?

Well, the proper response is that the Michigan Office of Attorney General does deal with "child matters." As a matter of fact, there is an entire division dedicated to "child matters" called the Children and Youth Services Division. Oddly enough, the Division only deals with child matters in Wayne County by making the county the only one in the state whereby the Attorney General prosecutes child abuse and neglect matters.

So, how is it that the Attorney General can investigate fraud and protect vulnerable children when the Attorney General is the one advocating for the ones who are the fraudfeasors?

The answer may not be a clear as one would imagine.

At first glance, you see an inherent conflict of interest; this being the Attorney General would have to investigate and advocate, prosecute and defend, or basically, snitch on himself. This is only the first layer.

The next layer is a question of an independent and autonomous authority to investigate and refer Medicaid Fraud for prosecution and recovery. This would be the co-location of authority of the Office of Children's Ombudsman (OCO). The office is, or was, situated in the Department of Management of Budget. Targeted Case Management is a Medicaid funded program for foster care, adoption and juvenile justice. The OCO has the formal authority, through statute and autonomy, to investigate complaints dealing with children in these Medicaid programs, and to make referrals to the counties prosecutors or Attorney General when Medicaid Fraud is suspected. OCO has never made one referral of suspected Medicaid Fraud for prosecution and recovery.

Unfortunately, the DHHS Secretary has certified Michigan's Medicaid Fraud Unit, even though its functions of controlling Medicaid Fraud in child welfare programs are non-existent.

2. Must each state have a MFCU?

Under federal law, each state must have a Unit unless the state demonstrates to the satisfaction of the Secretary of the Department of Health and Human Services that a Unit would not be cost effective because minimal fraud exists in the state's Medicaid program and Medicaid beneficiaries will be protected from abuse and neglect.

3. What is the jurisdiction of a MFCU?

A Unit's function is to conduct a statewide program for the investigation and prosecution of health care providers who defraud the Medicaid program. In addition, a Unit reviews complaints of abuse or neglect against patients in health care facilities receiving Medicaid funding and may review complaints of the misappropriation of patients' private funds in these facilities. The Unit is also charged with investigating fraud in the administration of the Medicaid program. The Ticket to Work and Work Incentives Improvement Act of 1999 authorizes the Units, with the approval of the Inspector General of the relevant federal agency, to investigate fraud in other federally-funded health care programs, if the case is primarily related to Medicaid. This section also authorizes the Units, on an optional basis, to investigate and prosecute resident abuse or neglect in non-Medicaid board and care facilities.

In Michigan, investigations of child resident abuse or neglect falls under the jurisdiction of the Department of Human Services (DHS), the same entity that is procures contracts of residential programs. The Bureau of Children and Adult Licensing (f.k.a. Office of Children and Adult Licensing and was located, independenty, in the Department of Energy, Labor and Growth) has the statutory authority to investigate and protect vulnerable children in receiving care from a licensed facility, particularly under the auspices of the state. This small group of investigators generate findings reports, but are not obligated to refer suspected and substantiated matters of Medicaid Fraud to any law enforcement authority.

4. How are MFCUs funded?

MFCUs receive annual grants (Federal Financial Participation or "FFP") from the U.S. Department of Health and Human Services. Grant amounts must be matched with state funding. Initially, a Unit receives federal funding at a 90 percent level. After its first three years, the FFP is reduced to 75 percent.

The FFP is reduced because the states MFCU are to become sustainable in the prosecution and recovery of Medicaid Fraud. Michigan has finally effectuated (rather semi-effective because there is very little civil incentive for individual referrals of Medicaid Fraud) and enhanced Medicaid False Claims Act. The point of this being the state will aggressively target and capture the recovery funds of Medicaid Fraud. By doing so, the state is allowed to recovery %10 of the FFP.

Alas, in the realms of child welfare, this has never been done.


5. What are the limitations on federal financial participation?

Federal financial participation is authorized for full-time attorneys, investigators and auditors involved in the investigation and prosecution of matters within the jurisdiction of a Unit. Full-time employees are required to be hired to perform full-time duty intended to last at least a year. Federal grant money may also be used for part-time support staff but only to the extent that these part-time employees participate in work activities that further the jurisdictional duties of the Unit. Finally, FFP is available to the Unit's parent agency to cover all indirect costs associated with the operation of the Unit.

Here is a really fun little item: "If the OCO is the co-location of authority to investigate Medicaid Fraud, matters well within the jurisdiction of the Medicaid Fraud Unit, and it never refers suspected and/or substantiated Medicaid Fraud, is FFP being used, and if it is, is being used to cover the state share of the percentage formula?


6. What are MFCU minimal staffing levels?

A Unit is intended to operate using a "strike force" concept of investigators, auditors and attorneys working together full-time to develop Medicaid fraud investigations and prosecutions. The staff of the Unit must include attorneys experienced in the investigation and prosecution of civil fraud or criminal cases, auditors capable of supervising the review of financial records, and investigators with substantial experience in commercial or financial investigations. If a Unit lacks direct prosecutorial authority, it must have a formalized procedure in place for referring cases to the appropriate prosecutorial authority.


Due to the fact that Michigan Medicaid Fraud Unit has never engaged in "strike force" operations, especially in child welfare, H.E.A.T. has stepped up to the plate.

7. What is the extent of federal oversight over a MFCU?

Each Unit operates under the administrative oversight of the Inspector General of the U.S. Department of Health and Human Services and must be recertified annually. As part of the recertification process, the Inspector General reviews a Unit's application for recertification and may conduct on-site visits. Additionally, the MFCUs are required to submit annual reports to the Inspector General. These reports include specific statistical data required by federal legislation on the number and type of cases under investigation, the number of convictions obtained and the number of dollar recoveries to the Medicaid program. The day-to-day supervision of a Unit rests with the parent agency.


8. How do Medicaid fraud cases typically arise?

While specifics may vary from state to state, a primary source of referrals is the agency responsible for auditing and reviewing Medicaid provider claims, the Medicaid agency. Other significant sources of referrals are the MFCUs in other states as well as other law enforcement agencies.

In Michigan, there are multiple "co-locations" to make primary referrals, but nobody does it. The investigative reports fade into the shadows of internet archives, and rather quickly, I must say!

This is one of my favorite examples of the non-existence of referrals in Michigan:

Michigan Office of the Auditor General, Audit Report, Financial Audit Including the Provisions of the Single Audit Act of the Department of Human Services, October 1, 2004 through September 30, 2006, Report #: 431-0100-07, (Pages 101-102). Thomas H. McTavish, C.P.A., Auditor General. (Released August 2007).

“DHS is primarily responsible for the expenditure of Foster Care: Title IV-E Program funds.

DHS has a contract with Wayne County to provide funding to Wayne County for eligible juvenile justice children. DHS considers Wayne County to be a subrecipient.

In order to be reimbursed, Wayne County submits a billing, which lists the Wayne County juvenile justice children for whom they are requesting reimbursement. DHS does not verify the eligibility of the children for whom they are paying. We were informed by DHS that the documentation would be retained by Wayne County because it was Wayne County that was responsible for continued eligibility determination. However, in our discussions with Wayne County, we were informed that it was DHS who was responsible for the continued eligibility determinations. The contract between Wayne County and DHS was silent on who was responsible for the continued determination.

As the grantor of the federal funds, OMB Circular A-133 requires DHS to monitor the program to ensure that the funds are expended for only eligible children. Because of the lack of understanding between the two parties and the lack of documentation for the items we reviewed, we have questioned all of the amounts provided to Wayne County for the two years ended September 30, 2006.” (Emphasis added)

The Audit Report continues to say in part:

“If DHS did not improve, it faced a possible penalty of $22 million”…. “The U.S. Department of Health and Human Services conducted the second eligibility review of DHS’s case files for foster care maintenance payments issued between April 1, 2006 and September 30, 2006. Prior to the review, DHS conducted an extensive case file review to identify cases that did not meet Foster Care: Title IV-E Program eligibility requirements. For cases that DHS determined did not meet the Foster Care: Title IV-E Program eligibility requirements, DHS changed the funding source on the cases to a funding source other than Foster Care: Title IV-E Program before April 1, 2006… As a result, those cases were not in the population reviewed during the federal review…The federal review concluded that DHS was in substantial compliance with federal eligibility requirements for the period April 1, 2006 through September 30, 2006.

We issued a qualified opinion on the Foster Care: Title IV-E Program. Our conclusion is different from the federal review because our sample included cases from the entire audit period.

RECOMMENDAITONS
FOR THE THIRD CONSECUTIVE AUDIT, WE RECOMMEND THAT DHS IMPROVE ITS INTERNAL CONTROL OVER THE FOSTER CARE: TITLE IV-E PROGRAM TO ENSURE ITS COMPLIANCE WITH FEDERAL LAWS AND REGULATIONS REGARDING ACTIVITIES ALLOWED OR UNALLOWED, ALLOWABLE COSTS/COST PRINCIPLES, AND ELIGIBILITY.

We also recommend that DHS improve its internal control to ensure compliance with federal laws and regulations regarding subrecipient monitoring.”

TRANSLATION: "TAG, YOU'RE IT!"


9. How do the multi-state/federal global settlements arise and how are they handled?

Medicaid fraud global settlements generally arise in connection with a U.S. Department of Justice investigation against a Medicare provider. When resolving these Medicare cases, the federal government, often at the request of defense counsel, turns to the state MFCUs because it cannot settle the Medicaid portion of the case without the Units. Moreover, defense attorneys are unlikely to settle the case without the affected states because each state has the authority to exclude a convicted provider from its health care programs. The Department of Justice typically contacts the National Association of Medicaid Fraud Control Units about a potential settlement, and the President of the Association appoints a settlement team which usually consists of three to four members.

Michigan has no exclusionary database because Medicaid Fraud in child welfare programming is never referred for prosecution. In the Michigan Auditor General Annual Report 2008, the imperative was revisited for a fourth time, for Department of Human Services to engage in contractual debarment and assessing sanctions for questionable and improper payments, and lack of internal controls.

10. What federal consequences follow a felony conviction for Medicaid fraud?

Under federal regulations, providers who are convicted of a program related offense are excluded for a minimum of five years from receiving funds from any federally funded health care program, either as a health care provider or employee. Often, this sanction has a greater impact on the convicted individual and the provider community at large than the criminal penalties assessed in the case.

The world eagerly awaits the first felony conviction in Michigan.

11. What is the National Association of Medicaid Fraud Control Units (NAMFCU)?

The National Association of Medicaid Fraud Control Units (NAMFCU) was founded in 1978 to provide a forum for a nationwide sharing of information concerning the problems of Medicaid fraud, to improve the quality of Medicaid prosecutions by conducting training programs, to provide technical assistance to Association members and to provide the public with information about the MFCU program. All 50 MFCUs are members of the Association. NAMFCU is headquartered in Washington, D.C. and is staffed by a Counsel, an Association Administrator and a part-time Association Assistant.

Here is my take on the National Association of Medicaid Fraud Control Units:

SQUAMULOUS LAGS.

I submit that NAMFCU needs to be put on the H.E.A.T. "laundry list."

Idaho’s Medicaid payments for prescription drugs questioned

IDAHO EXAMINES TOP PRESCRIBERS

Idaho Statesman
Idaho’s Medicaid payments for prescription drugs questioned
But the state says Medicaid records don’t prove doctors are overprescribing
November 11, 2012
By AUDREY DUTTON

Idaho Medicaid Dick Armstrong addresses the State Legislature

U.S. Sen. Chuck Grassley, an Iowa Republican who has assumed a role as a taxpayer watchdog, says some Idaho physicians have overprescribed antipsychotic drugs and addictive narcotics such as OxyContin to Medicaid patients.

“After an extensive review of prescribing habits of the serial prescribers of pain and mental health drugs in your state, I have concerns about the oversight and enforcement of Medicaid abuse in your state,” Grassley wrote in a Jan. 23 letter to Idaho Department of Health and Welfare Director Dick Armstrong.

Grassley asked for a list of the state’s top prescribers of certain drugs that have a high potential for addiction or that have been scrutinized for misuse in certain patient groups, such as in nursing homes.

“Mental health drugs continue to be prescribed at astounding rates, and pain management clinics are turning into a hotbed for black market painkillers,” he wrote.

The state sent Grassley records of prescribing activity by Medicaid providers for 2008 and 2009. Grassley called the numbers “shocking.” The state then sent him records for 2010 and 2011.

- One doctor wrote about 4,870 prescriptions in 2010 and 2011 for four of the antipsychotics, with Medicaid payments for them totaling $1.7 million.

- A nurse practitioner in 2008 wrote 106 OxyContin prescriptions totaling $42,768, and the following year a doctor wrote 102 OxyContin prescriptions for $56,737.

- Four Medicaid providers wrote more than 300 prescriptions each for the sedative Xanax in 2011.

- For one kind of drug, the atypical antipsychotic Abilify, Medicaid paid about $2.5 million for prescriptions written by 10 health care providers in 2011.

- Medicaid paid about $269,000 for the painkiller oxycodone prescribed by the most frequent providers in 2011.

The top prescribers represented only a fraction of the 11,000 to 18,000 medical providers who served Medicaid patients in those years.

The payments for their prescriptions made up a sizable share of the total spending in those years. The Medicaid program spent $61 million to $83 million per year on prescribed drugs between 2008 and 2011. The total billed to Medicaid for Abilify in 2008 by the top 10 prescribers was more than $1 million.

The most frequent prescribers for the eight drugs in question include two doctors who have been disciplined by the Idaho Board of Medicine for reasons unrelated to Grassley’s concerns. They also include doctors, nurse practitioners and physician assistants who have taken payments or gifts from drug companies since 2009. A few collected more than $10,000 for speaking and consulting work.

Grassley has sent similar letters to many other states. His office said it had no record of a response from Idaho as of last week, but the Idaho Department of Health and Welfare provided the Statesman a copy of its response sent in March.

“The number of prescriptions written by these prescribers … does not necessarily indicate overprescribing or inappropriate prescribing,” wrote Medicaid Administrator Paul Leary. Mental health or pain specialists will, by nature of their jobs, have more patients who need those drugs, he wrote.

Indeed, the top physician prescribers for the drugs were, in most cases, psychiatrists, pain specialists or cancer specialists.

Grassley asked the state to explain whether it monitors its Medicaid-billing doctors to make sure they don’t have black marks on their records. Leary said Medicaid does that only if it finds that a provider isn’t appropriately prescribing drugs.

Medicaid has no system to spot excessive prescription writing, but the Idaho Board of Pharmacy has a prescription-monitoring program and would be responsible for flagging overprescribers, Leary said.

A NARCOTIC PROBLEM

Though the Idaho Medicaid program does not oversee the people writing the prescriptions, it has identified a problem with drug-seeking patients and is working on ways to curb it.

If a patient is on Medicaid, he or she is restricted to a certain number of doses per day and prescriptions per month. More than 100 drugs require an authorization from Medicaid before they can be filled, Leary said.

The use of psychotropic drugs in certain Medicaid populations has prompted federal studies.

According to a report by the Government Accountability Office late last year, children in the foster care system were much more likely to be on at least one psychotropic drug — sometimes more than five at once. The office said federal guidance could help with state-run oversight of prescriptions for children.

That is something Idaho’s Medicaid program might be addressing.

“The Medicaid Pharmacy Program is … participating in a project with other areas of the Idaho Department of Health and Welfare and various community organizations to improve the use of psychotropic drugs in foster kids,” Leary wrote.

He added that he expects to set up a system for red-flagging possible misuse, making sure there is consent for treatment and getting prior authorization when necessary.

According to Medicaid data, about 24 percent of foster children were prescribed psychotropic drugs in 2008, compared with 7 percent of children not in foster care.

However, as the GAO noted, higher rates could be partly due to mental-health needs, traumatic life events and fragmented medical care of foster children compared with nonfoster children.

A federally mandated board in Idaho is looking at abuse-prone prescription drugs among the state’s Medicaid patients.

An October report profiled 150 patients who received the most narcotics through Medicaid in an eight-month period.

The average patient was on three opioid drugs — painkillers such as OxyContin — prescribed by four health care providers. They had been on the drugs for several years. The most common diagnoses were back pain, chronic pain and vertebrae disc problems. About 39 percent of them also had diagnosed problems with drug abuse.

When the board cross-referenced Idaho Board of Pharmacy information, it found that 30 percent of the high-narcotic Medicaid patients were also paying cash for separate prescriptions. The extra number of doses ranged from two to 4,275 in the eight-month span.

Idaho Medicaid is putting some new rules in place for certain narcotics to cut down on the potential for abuse, the report said. They include making sure that three less problematic drugs have failed to help a patient before the patient is switched to a narcotic such as OxyContin or Vicodin.

A panel appointed by Gov. Butch Otter recommended Friday that the Legislature broaden Idaho’s Medicaid program to cover more than 100,000 additional low-income residents.

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