How New York is enabling rampant Medicaid fraud | New York Post – New York Post

In New Jersey, the police have an odd enforcement tactic against drunken driving. Cops often list in newspapers the specific areas where there will be DWI checkpoints.

Why? I don’t know. Anyone planning to get boozed up and behind the wheel can simply go a different way and not get caught.

New York does pretty much the same thing in going after Medicaid fraud, according to a well-connected whistleblower who doesn’t want me to reveal his name. Each year, the New York State Office of the Medicaid Inspector General issues a “Work Plan” — a “blueprint,” it’s called — that explains what enforcement actions will be on the agenda.

For example, the 2017-2018 Work Plan for “Protecting the Integrity of the Medicaid Program” lists these as the focus for this year: Combatting Prescription Drug and Opioid Abuse; Home Health and Community-Based Care Services; Long-Term Care Services; Medicaid Managed Care and Transportation abuses.

So if you want to get away with cheating the Medicaid system — like those drunken drivers in New Jersey — just avoid those areas of fraud. In other words, steal Medicaid money from somewhere else.

In case you don’t already know, Medicaid is a joint federal and state program that provides millions of low-income Americans with medical coverage. It’s administered by the states but the feds set the rules.

Over 6 million New Yorkers receive services from Medicaid, and there are 80,000 health care providers in the state attached to the system. Medicaid spending in New York is expected to be $65 billion in the 2018 fiscal year.

And, like every other government program, there are abuses.

Perhaps the biggest trick with Medicaid is this: Move assets out of the name of elderly people in order to make them qualify for Medicaid benefits, which can get them free care in a nursing home among other things.

That’s legal, although there is a “look back” period before this trick works. In fact, until the system is changed, I recommend you do it.

But that’s not what the state will be looking at this year — cheating on prescription drugs, home health care, long-term care, managed care and transportation abuses are.

My source says the state feels like it needs to give health care providers some sort of “transparency” in its enforcement efforts. “Providers want a heads-up,” this source says.

Bank robbers would like a heads-up also — where will the cops be when they announce “Stick ’em up?” And everyone would like to know what the IRS looks for when they are trying to cheat on their taxes.

“It’s like an open book examine,” says my source about the Medicaid enforcement system. He thinks it is OK to tell health care providers some information, but “don’t give them too much detail.”

The other problem, my source says, is after the cheaters get caught — if they are caught — they are inevitably cut a deal. Why? Because all those big hospitals and rich doctors are going to hire lawyers and drag out the proceedings. And that’s going to cost the state money.

Typically, he says, the state will settle for a mid-point figure in the estimated fraud “unless the findings are solid.”

And sometimes, this source says, New York exaggerates the amount recovered from fraudsters. That creates its own problem because giving an inaccurately high amount often leads to Washington expecting the state to return more money in federal aid than it actually should.

I’m just starting to look into various instances of fraud against US taxpayers. In my last column, I pretty much wrapped up my investigation against abuses committed by the Census Bureau in giving out contracts without going through competitive bidding.

The Commerce Department’s Inspector General, who oversees Census, reported widespread abuse in contracts given out on what’s called a “sole source” basis — without bidding.

My secret whistleblower in the Medicaid case, who for years was in a position to know about fraud, sent me a letter recently explaining that New York needed to keep the welfare fraud rate below the 5 percent level or it would have to return some of the contribution made to the system by the feds.

“For example,” he wrote me, “the New York State Department of Social Services developed a quality control audit program that consistently produced data based on flawed surveys and home visits that showed welfare-recipient fraud was always under 5 percent.”

“This was a phony statistic and everyone knew it, including the auditors,” he wrote.

The marching orders from Albany were to always “maximize federal reimbursement” of welfare money. And that couldn’t be done if too much fraud was reported.

Let me get back to the 2017-2018 Work Plan for “Protecting the Integrity of the Medicaid Program.

“Health care fraud, waste and abuse can involve physicians, pharmacists, nurses and aides, recipients, medical equipment companies, managed care organizations and transportations providers, among others,” the Work Plan says.

Well, all of those potential cheaters are happy to know what enforcement will focus on this coming year.

Me? I’m not going to tell you what sort of investigations I will do in the year ahead, mainly because I don’t know. It’s up to people with a conscience to write to me when they see something wrong, when they see someone cheating, stealing, lying or acting badly — especially when it’s hurting taxpayers.

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