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Recoveries jump for Medicaid fraud unit

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The Medicaid fraud control unit in the office of state Attorney General Gary King has made a sharp turnaround over the past several months after years of subpar performance.

Since the start of the 2014 federal budget year on Oct. 1, the unit has recovered nearly $9 million – more than it had recovered in the three previous years combined, according to statistics provided by King’s office.

The unit also has conducted more than 180 investigations since Oct. 1 – compared with 112 for the previous year, the stats show.

The Republican Governors Association, citing a Journal editorial in 2011, has been airing a television commercial saying that King had one of the worst records in the country at stopping Medicaid fraud.

King is the Democratic nominee challenging GOP Gov. Susana Martinez’s bid for re-election in November.

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

The Journal editorial cited by the Republican Governors Association was based on initial federal statistics showing the fraud unit cost more to operate than it recovered in criminal and civil cases in the 2010 federal budget year.

Revised federal statistics showed that $1.8 million in state and federal funds were spent on the unit’s operation in the 2010 federal budget year and that it recovered $2.4 million.

Recoveries were $3.4 million in the 2011 federal budget year, $3.6 million in 2012 and $2 million in 2013. Throughout those years, the New Mexico fraud unit ranked near the bottom among other states and the District of Columbia when it came to return on investment.

In a review of the unit released in 2011, the 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 spokesman Phil Sisneros said the attorney general, who took office in January 2007, has made a “concerted effort” to improve the unit’s operation.

“We clearly recognized that we had problems in recoveries and across the board,” Sisneros said.

A follow-up report issued last year by the staff of the Legislative Finance Committee found improvements in the unit’s operation, including additional training for staff, prioritization of investigations and a reduced caseload.

“Things are more efficient and effective,” said Patricia Padrino Tucker, the unit’s deputy director.

The Medicaid fraud unit gets referrals from a telephone hotline, nursing homes, state agencies, law enforcement, whistleblowers and others.

Tucker said the unit has streamlined its procedures for assessing potential cases and moving forward on cases when warranted. Also, the unit now has better-skilled staff, she said.

The spike in recoveries since the start of the 2014 federal budget year has been due in large part to an increase in recoveries resulting from whistleblower complaints about Medicaid fraud, Tucker said.

The recoveries include a $2.2 million settlement with Janssen Pharmaceuticals and $1.7 million and $4.4 million settlements with the pharmaceutical giant GlaxoSmithKline.

The settlement with Janssen and the smaller of the settlements with GlaxoSmithKline resulted from multistate litigation over the companies’ marketing of drugs, according to the Attorney General’s Office. The office settled separately with GlaxoSmithKline in the larger settlement.

The staff of the Legislative Finance Committee also has reported that the Department of Human Services under Gov. Martinez has strengthened its efforts to detect Medicaid fraud and respond to fraud concerns of program participants.

The department cut off Medicaid funding in June 2013 to 15 nonprofits, alleging an audit showed overbilling and possible fraud by the providers of mental health and other behavioral health services.

Human Services turned over the audit to King, whose office has since said it found overbillings but no fraud on the part of two of the providers. Investigation results for the other providers haven’t been announced.

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 ABQjournal.com/letters/new to submit a letter to the editor.

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