Florida Elder Law And Medicaid Fraud

Senate.gov, Mar 28, 2007

Vigorous oversight hasn’t seemed important to many state health-care bureaucrats who administer Medicaid, either. A 2005 investigation by Ohio’s inspector general, for instance, found that health officials in that state prefer to “educate” doctors, hospitals, and others who overbill Medicaid rather than refer cases for investigation and possible prosecution. Sloppy record keeping and slack pursuit of wrongdoers are endemic. The Ohio agency that supervises Medicaid proved so careless with taxpayer dollars that it accepted a mere $409 to settle a $500,000 overpayment to an ambulance service. In another case, the state demanded payment of just $155,000 from speech centers that had overbilled by $3.4 million. Florida’s Medicaid fraud unit couldn’t tell auditors what happened to $133,000 in fines levied against one defendant—or if the state had ever gotten paid. More outrageous still, the unit settled a $40 million fraud case against nursing-home operators for a mere $100,000. A federal investigation warned Florida that its anti-Medicaid-fraud effort was so slipshod that it risked losing federal funding.

Even with tougher enforcement, states must confront the troubling reality that Medicaid programs have grown too large and complex to manage easily. With even faster growth rates projected in the immediate future, trying to minimize fraud, waste, or simple errors in Medicaid will only get harder. “All this complexity has created a breeding ground for fraud and abuse,” Florida governor Jeb Bush said last year.

That’s why the best idea for reducing fraud over the long term may be Florida’s push to overhaul its entire Medicaid program. Last fall, the federal government gave Florida permission to try a drastic revamping of the system. The state will stop acting as a giant health insurer and instead move recipients into private plans. Florida will pay the insurance companies a yearly fee to enroll the recipients, in the same way that a private employer now pays for its employees to receive health coverage. As in the private sector, each insurer will be responsible for auditing bills and sniffing out fraud by providers or recipients in its system. In effect, Florida will be breaking its Medicaid system into dozens of smaller units, managed by the private sector, where lax efforts to eliminate waste, inefficiency, and incorrect billings will eat away at companies’ bottom lines.