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AG’s Fraud Unit Recovers More, Still Ranks Low

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The Medicaid fraud control unit in the office of state Attorney General Gary King has stepped up its game but remains among the worst-performing units in the nation by some measures.

That’s according to statistics compiled by the U.S. Department of Health and Human Services for the 2011 federal budget year.

King’s unit recovered nearly $3.4 million in criminal and civil Medicaid fraud cases in the 2011 budget year. That’s up 39 percent from $2.4 million in the previous year.

The unit also improved when it came to two other performance measures but still ranked near the bottom nationwide.

The amount it recovered per $1 million in Medicaid spending was $988. Only four states did worse. Medicaid spending totaled $3.4 billion in New Mexico in 2011.

The amount the unit recovered per $1 spent in fighting fraud was $2.74. Only seven states and the District of Columbia did worse. The unit spent more than $1.2 million.

The New Mexico unit has a long way to go to become average.

Nationwide, Medicaid fraud control units recovered an average of about $3,700 per $1 million in Medicaid spending and nearly $10 per $1 spent in fighting fraud.

The Medicaid Fraud and Elder Abuse Division within the AG’s Office is responsible for investigating and prosecuting fraud by Medicaid providers and abuse of aged residents in nursing homes and elsewhere.

Asked for comment for this story, the AG’s Office provided a copy of a letter sent last January from the National Association of (state) Medicaid Fraud Control Units to the federal director of Medicaid fraud policy and oversight.

The association said using statistics on financial recoveries to evaluate a law enforcement agency is inappropriate and may result in unfair comparisons of Medicaid fraud units.

“Prosecutorial activity cannot be measured by standardized measurement, review and comparison,” the letter said. “Each unit is different and operates differently.”

King has said previously that focusing on recoveries doesn’t produce a true picture of his unit since its responsibilities include investigating and prosecuting elder abuse and that such cases typically don’t produce a recovery.

“Attorney General King remains focused on providing protections to the fragile and frail in New Mexico who are most often victimized by Medicaid fraud,” a spokesman for the AG wrote in an email Tuesday.

The stakes in the fight against Medicaid fraud are large.

Nationwide in the 2011 federal budget year, Medicaid expenditures totaled more than $420 billion.

By one estimate, there is about $75 million worth of fraud each year in New Mexico, and providers – those are the folks the Medicaid fraud unit is supposed to go after – account for the overwhelming majority of the stealing.

The Medicaid fraud unit gets referrals from a telephone hotline, nursing homes, state agencies, law enforcement and others. Like Medicaid, the unit is funded with federal and state dollars.

In a review of the unit released last year, staff of the Legislative Finance Committee found it was underperforming, given its funding and staff.

The review found a high rate of outstanding referrals to the unit and a backlog of open cases. It also reported problems in the unit’s organizational structure, including too few special agents, and a high job vacancy rate.

King agreed to conduct an internal review of how the unit prioritizes cases and allocates staff.

UpFront is a daily front-page news and opinion column. Comment directly to Thom Cole at tcole@abqjournal.com or 505-992-6280 in Santa Fe. Go to www.abqjournal.com/letters/new to submit a letter to the editor.
— This article appeared on page A1 of the Albuquerque Journal

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