Their view

Rooting out Medicaid fraud demands new leadership

By Patrick Morrisey - Contributing Columnist



Waste, fraud and abuse are rampant nationwide and West Virginia certainly is no exception.

This reality harms safety net programs, such as Social Security, Disability, and Medicaid. The unlawful taking from any of these programs wastes tax dollars, deepens deficits, and jeopardizes the very programs designed to help those most in need.

A responsible government, accountable to its citizens, cannot condone such behavior. It must attack waste, fraud and abuse at every level and as Attorney General, I am committed to doing just that.

In just nine months, my office’s commitment to rooting out disability fraud yielded a projected savings of more than $1.4 million for state and federal government – a result that will grow by leaps and bounds in the months and years to come.

Now it’s time the state Legislature equip my office to punish those who defraud Medicaid.

Most every state in the nation, including West Virginia, has established a Medicaid Fraud Control Unit to investigate and initiate civil and/or criminal prosecutions against those who attempt to abuse Medicaid.

But the Mountain State is an outlier in that its primary unit for investigating Medicaid fraud falls under the jurisdiction of the Department of Health and Human Resources. The vast majority of the units are run by state attorneys general.

While DHHR is the self-described “single entity” for investigating Medicaid fraud in West Virginia, it has proven ill-equipped to adequately police fraud and abuse.

The most recent legislative audits reveal a number of critical shortcomings.

For instance, the September 2013 Performance Update compiled by the Legislative Auditor revealed 171 backlogged referrals within West Virginia’s Medicaid Fraud Control Unit, with 23 of those cases dated as far back as five years.

The 2013 audit recommended West Virginia’s unit work “to strengthen detection and prevention strategies against wasteful spending and fraud; implement new deterrents against providers who seek to commit fraud; reduce the length of time between the detection, investigation, and prosecution of fraud; and improve inter-agency communications.”

Its findings triggered legislative hearings, including one during which a research analyst testified, “as you can see, suspicious billings from providers can remain uninvestigated for years.”

This is completely unacceptable.

Our state can do better – much better – and the potential for generating far more in additional savings demands new oversight and leadership of this critical investigative unit.

Perhaps this is best demonstrated by the ratio of Medicaid dollars paid for fraudulent claims to dollars recovered.

While it is difficult to quantify the precise monetary damage Medicaid fraud inflicts nationwide, it has been projected that anywhere from 5 to 20 percent of every Medicaid dollar is expended toward a fraudulent or wasteful claim.

That means, by even conservative estimates, West Virginia’s Medicaid program may have lost well over $100 million to Medicaid fraud during the state’s 2015 fiscal year. If you calculate that just 2.5 percent of Medicaid’s total cost of $4 billion is impacted, that is a significant sum of money.

By contrast, a February 2015 press release states DHHR’s Medicaid Fraud Control Unit recovered just $40 million during its previous two years – this means that we’re leaving a lot of money on the table.

While I am sure that DHHR has taken steps to remedy the dysfunction highlighted by the most recent audits, my office is best positioned to fix these deficiencies and operate the Medicaid Fraud Control Unit with greater efficiency and effectiveness to the benefit of the taxpayer.

In fact, of the 49 states and the District of Columbia with operating Medicaid Fraud Control Units, 42 are operated by the state’s attorney general.

This trend, combined with our office’s vigorous pursuit of those who defraud consumers and disability benefits, should leave the West Virginia Legislature with one option: the status quo should no longer be tolerated.

As Attorney General, and as a Mountain State taxpayer, I want to ensure these funds go to provide medical care for our low-income residents and families who legitimately need the assistance – not to waste and mismanagement by fraudulent bad actors.

My office has a proven track record of success in protecting West Virginia taxpayers by aggressively pursuing enforcement actions against those who commit disability fraud or violate the state’s consumer protection laws.

Our office will focus that same energy in combating Medicaid fraud, the result of which can lead to a more competitive tax code and greater economic development to help West Virginia reach her full potential.

If you oppose higher taxes and want to ensure that some monies are maintained for those who need it most, you will support this plan.

Rooting out Medicaid fraud demands new leadership

By Patrick Morrisey

Contributing Columnist

Patrick Morrisey is the Attorney General of West Virginia.

Patrick Morrisey is the Attorney General of West Virginia.