The office of state Attorney General Gary King obtained convictions last week against a Las Cruces company and four individuals on Medicaid fraud and other charges.
King announced the successful prosecution in a two-page news release, congratulating his Medicaid fraud unit for its “perseverance and ability to take these cases all the way.”
You can’t blame the attorney general for trying to get some good public relations when the Medicaid fraud unit does something. That’s because the unit, by a couple measures, doesn’t do a whole lot.
Consider these statistics, which are based on data for the 2010 federal budget year and provided by the U.S. Department of Health and Human Services:
n King’s Medicaid fraud control unit recovered just 53 cents for every $1 it spent to fight fraud. (The recovery rate was about half of what it was in 2008.) Only Alaska had a worse record. Missouri was best, with more than $31 recovered per $1 spent. The average for all state Medicaid fraud units was more than $10 recovered per $1 spent.
n The Medicaid fraud control unit recovered $269 in criminal and civil cases for every $1 million in Medicaid spending. Only Alaska and Arizona did worse. Utah was best, with $16,470 recovered for every $1 million in Medicaid spending. The average for states was just over $4,200 per $1 million spent.
Of course, these statistics wouldn’t be a big deal if Medicaid weren’t such a big deal. In the 2010 federal budget year, the state spent $3.5 billion on the health care program for low-income adults and children.
If New Mexico’s Medicaid fraud unit had performed just average when compared with units in other states, it would have collected $18.5 million from criminal and civil defendants in the 2010 federal budget year. Instead, it brought in less than $1 million while spending about $1.8 million on its operation.
And, just so you know, there is a lot of Medicaid fraud going on in New Mexico.
By one estimate, there is about $75 million worth of fraud each year, and providers – those are the folks the AG’s Medicaid fraud unit is supposed to go after – account for 80 percent of the $75 million.
Now, for a little background, then we’ll hear from the attorney general.
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.
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 Medicaid fraud unit released over the summer, staff of the Legislative Finance Committee found the unit was underperforming, given its funding and staff. Other states are doing more with less, the report said.
The review found a high rate of outstanding referrals to the Medicaid fraud 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 responded to the report in a four-page letter to the LFC staff.
The AG noted that the responsibilities of the Medicaid fraud unit include investigating and prosecuting elder abuse but said such cases typically don’t produce a financial recovery.
“Accordingly, the report’s emphasis on return on investment does not present a true picture of (the unit’s) overall efficiency and performance,” King wrote.
True enough, but Medicaid fraud units in other states manage to recover more money while also investigating and prosecuting abuse of the aged.
Also in his response, King said New Mexico generally recovers less in Medicaid fraud than other states because of its heavy reliance on managed care organizations to deliver benefits.
The AG agreed with the review that the Medicaid fraud unit and the Human Services Department, which runs Medicaid, need to communicate better on referrals.
King also agreed to conduct an internal review of how the unit prioritizes cases and allocates staff.
In addition to the Medicaid fraud unit, the staff of the Legislative Finance Committee examined the work of the Human Services Department in investigating fraud by Medicaid recipients. The review found room for improvement there, as well.
LFC Chairman John Arthur Smith, a Democratic senator from Deming, told a committee hearing in July that there is a perception that virtually nothing is being done to combat Medicaid fraud.
Hard to argue with the man.
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.
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