Medicaid fraud, quality oversight lacking

Despite evidence of fraud or poor patient care within the Medicaid program, several states, including Florida, Illinois and Ohio, hesitate at terminating Medicaid contracts, The Washington Post and Kaiser Health News reported.

According to healthcare experts, states avoid dropping Medicaid plans to prevent patients from having to switch doctors and prescription drug plans, the article noted.

So instead of pulling the plug on Medicaid contracts, states impose financial penalties, financial incentives or limitations on enrolling new beneficiaries to motivate plans that violate rules or perform poorly.

State health officials are responsible for monitoring and overseeing plans that provide services to patients on Medicaid, as well as enforcing Medicaid contracts and policing problem plans. However, industry experts question whether states take enough action to crack down on fraud and ensure quality services.

"If you're going to talk the talk about enforcement, you better be prepared to walk the walk," Bill Mahon, former executive director of the National Health Care Anti-Fraud Association, told the Post and KHN." There's a lot of talk, but a lot less walk by the states."

For example, Florida health officials still contract with WellCare Health Plans, even after it faced criminal charges in 2009, and in June two former WellCare chief executives were found guilty of fraud. WellCare remains the largest Medicaid managed care plan in Florida, the Post and KHN noted.

And only last month, New Jersey's comptroller's office said UnitedHealthcare Community Plan failed to properly prevent fraud from the state's Medicaid program. The UnitedHealth subsidiary didn't hire and train enough fraud investigators, "overstated" its staff levels and didn't require its special investigations unit to focus on fraud detection, the report from the New Jersey Office of the State Comptroller found, FierceHealthPayer previously reported.

Yet health officials in Texas seem to taking a tough stance on Medicaid enforcement, suspending enrollment and imposing large fines on some plans and even revoking one of their plan's contracts, according to the Post and KHN.

For more:
- read the KHN-Post article

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