I try hard to stay focused on Dryden, but sometimes things at other levels get so rotten that it's hard to avoid the stench. The New York Times seems to be doing some basic research on Medicaid that the New York State Department of Health isn't doing, finding things like:
They ran a long article (registration required) on the potentially huge cost of these kinds of fraud yesterday, which reported that:
New York's Medicaid program, once a beacon of the Great Society era, has become so huge, so complex and so lightly policed that it is easily exploited. Though the program is a vital resource for 4.2 million poor people who rely on it for their health care, a yearlong investigation by The Times found that the program has been misspending billions of dollars annually because of fraud, waste and profiteering. A computer analysis of several million records obtained under the state Freedom of Information Law revealed numerous indications of fraud and abuse that the state had never looked into.
Today's article looks more closely at what the state is doing, or not doing, to battle fraud. A few key pieces:
Of the 400 million claims that Medicaid paid last year, Health Department regulators uncovered just 37 cases of suspected fraud, far fewer than their counterparts in any other large state, even though New York's Medicaid budget is by far the largest in the nation. Many experts say that it is likely that at least 10 percent and probably more of New York Medicaid dollars are stolen or wasted....
It often appears that the Health Department is barely even looking: There are more than 140,000 hospitals, nursing homes, doctors and other health care providers in the system, but the department visited just 95 in the 2004 fiscal year to audit their billings.
Analyzing Medicaid data obtained under the state's Freedom of Information Law, The New York Times identified scores of instances in which the claims of health care providers jumped markedly in a single year. These spikes are a classic indication of possible improper billing, yet few of those providers had even part of their billings audited by the department, state records show...
Meanwhile, other states, including California and Texas, have increased their antifraud efforts and discovered what seems a simple truth: The effort to seek out theft and unnecessary spending can more than pay for itself, just as a parking violations bureau brings in revenue. Workers assigned to Medicaid fraud prosecution units around the nation help bring in an average of $200,000 each in recoveries, according to federal statistics.
Twenty-five years ago, New York was in the vanguard of fraud prevention. But over the decades it has failed to maintain the investment in employees necessary to close the door on thievery and abuse. Repeated delays stretched the replacement of a 1970's-era computer system that could barely detect fraud into a seven-year ordeal, allowing billions to slip by with little scrutiny.
As dozens of former employees describe it, the state's antifraud effort has been plagued by the same gridlock that has stifled innovation in Albany for years: bureaucratic infighting, allegiance to campaign contributors from the health care field, reliance on public indifference...
But former senior department officials said most of the workers cited by Mr. Whalen [the executive deputy commissioner of the Health Department] are not actually investigating fraud. They are accountants, nurses, computer analysts, clerks and others doing administrative jobs, making sure basic regulations are followed, leaving only about 50 state employees dedicated to fraud work.
Mr. Whalen and his aides said new computers and software were helping the department shift its focus from reviewing Medicaid claims already paid to preventing questionable claims from being paid in the first place.
But state statistics show that the department rejected a much smaller percentage of claims in the 2004 fiscal year than its counterparts in California, Florida or Pennsylvania.
Asked to list cases that they developed that led to arrests and prosecutions, Health Department officials could point to only a handful in the last two years.
The result of the cuts is evident in case after case that the state simply missed. The billings of a Queens pharmacist, Newton Igbinaduwa, rose to more than $1.4 million in 2002 from $78,000 in 1998, according to billing records analyzed by The Times. But the department never referred the case to the state attorney general's office.
I don't want to see fraud investigators challenging every prescription which might or might not work for a particular problem, but the current lack of oversight appears to be missing fraud conducted on a very large scale. It doesn't speak well of the Department of Health that the New York Times is finding fraudulent dentists for them:
After The New York Times discovered her extraordinary billings through a computer analysis and questioned the state about them, Dr. Rosen and two associates were indicted on charges of stealing more than $1 million from the program.
Medicaid has been a huge factor in the recent ballooning of county property taxes, though the state finally put a cap on its increases for counties this year. I strongly support the program, but the program plainly needs at least basic supervision, with regular auditing and enough smarts to find basic problems like spectacular overbillings. Addressing this seems like a key first step toward reducing the impact of Medicaid on federal, state, and county tax bills.
NYCO also covers this, asking some tough questions.
Posted by simon at July 19, 2005 12:26 PM in politics (state) , public finance