As much as $50 million in public money is being lost to Medicaid fraud in Utah every year, and state investigators say it is time to start playing hard ball with Utah's health-care providers.
"We are going to go after them aggressively," said Capt. Roger Harris, Utah Division of Investigations. "We are going to commit whatever resources are necessary, and we're going to be using new approaches and new techniques."Medicaid fraud investigations have traditionally been the responsibility of the Utah Bureau of Medicaid Fraud. But that bureau was recently incorporated into the new Division of Investigations, which is also responsible for narcotics and smuggling investigations, intelligence gathering, organized crime investigations and other law-enforcement activities.
With the reorganization, Medicaid auditors now have at their disposal the investigative skills of state narcotics officers, intelligence officers and other experts within the division.
"In the past," Harris said, "they would receive a complaint, and they would act on that complaint. Now we are taking an aggressive, pro-active approach to the problem as well. We are going out looking for those abusing the system, and we're going to prosecute them more vigorously."
Not that Medicaid investigators don't want public complaints.
"We welcome complaints. We thrive on complaints. We relish complaints," Harris said. "The problem has been most people don't know the state investigates these kinds of complaints."
In many ways, the Bureau of Medicaid Fraud has been viewed as the forgotten child of law enforcement. Many law officers don't even know about the agency, and most of those who do don't bother to seek the expert assistance from state auditors and investigators.
"It's a situation that has to change," said Michael Hanks, director of the Utah Division of Investigations. "We've got to make the bureau a high-profile operation. We've got to make prosecutors and investigators around the state aware of what we can do."
Dennis Kroll, an assistant attorney general assigned solely to prosecute Medicaid fraud, agrees. "If we could just get better known, maybe we could start getting referrals from prosecutors," he said.
It's not that Medicaid fraud investigators are sitting around the office without anything to do, said chief investigator Susan Jones. Rather, it's that expertise could be put to more effective use. It's also a matter of the bureau not even scratching the surface of a severe problem.
Some $250 million in Medicaid funds are spent in Utah every year. If national estimates hold true, fraud is involved in as much as $50 million of that taxpayer money.
The bureau investigated about 60 cases last year and recovered about $78,000 mere pittance compared to estimated $50 million lost every year. The annual state budget for Medicaid fraud investigations is $530,000.
"We have quite a few big cases we don't have the resources to take on," Jones said. "We're not unwilling to take them on, but we have been unable to with the resources we have."
Medicaid Fraud Investigations is charged with probing abuses in the payments of Medicaid claims to health-care providers. That includes doctors, dentists, hospitals, medical suppliers, nursing homes, health-care specialists anyone who provides medical services that are reimbursed by state and federal Medicaid money.
The section has also been ordered to investigate cases of physical abuse, neglect or exploitation of individuals in nursing homes and hospitals.
Medicaid fraud is something easy for doctors, pharmacists and other providers to become involved in. Medicaid payment claims are processed with little scrutiny or review. Because of the sheer volume of claims, the payments are made "as quick as they can be keypunched into the computer," Kroll said.
The temptation is for health-care providers to bill for treatments not rendered or for more expensive treatments than those actually provided. The patient, who never sees the bill, has no idea what services are being paid for.
"Those practices escalate on them," Jones said. "It is so easy to get the money. And when they get caught, doctors are usually wealthy enough to resist prosecution. It's easy for a jury to believe simple mistakes were made."
That's why investigators must be able to prove ongoing criminal behavior. That requires exhaustive auditing of Medicaid receipts over a long period of time often years.
It also could mean "shopping" providers going undercover as health-care recipients and then comparing the Medicaid reimbursements. "You're going to see a lot more of those type of investigations," Harris said.
As Medicaid investigators become more aggressive and the resulting prosecutions become more high profile, the program will have a much greater deterrent effect.
"We have a deterrent effect now, even though we can't measure that effect in terms of dollars and cents," she said. "We know we do because every time we successfully prosecute a case, we are inundated with phone calls from health-care providers wanting to correct their billing practices."
The deterrence factor, though immeasurable, is the primary function of Medicaid fraud investigations, Jones said. If people know investigators are watching closely, they will "walk the straight line more closely."
Hanks has suggested prosecuting offenders under racketeering statutes that allow the state to confiscate all assets purchased with illegally obtained Medicaid money. Homes, cars and businesses purchased in whole or in part by illegally obtained money could be seized by law enforcement officers.
"That would be a real deterrent," Hanks said.