Local, state, and national politicians (and maybe some of your neighbors) are always complaining about how individuals are defrauding tax payers by relying on Medicaid as opposed to purchasing private health insurance or getting a job that provides health insurance to its employees.
Medicaid’s primary purpose is to provide health coverage to low-income individuals and families, ensuring access to essential medical care and services. It is a joint federal and state program, offering benefits that Medicare doesn’t always cover, such as nursing home care and personal care services. Medicaid operates as a vendor payment program, where states pay health care providers directly or through managed care organizations…and here is where the fraud comes in.
The Wall Street Journal conducted some research on Medicaid payments and published its findings in an article titled, Medicaid Spent Billions Covering Same Patients Twice.
I bet your first inclination was to conclude individuals were the fraudsters…the poor and downtrodden where again cheating the American taxpayers. If that was your first inclination about the findings by the WSJ you would be very wrong. What the WSJ uncovered was that the insurance companies (vendors) which provide Medicaid coverage in the states receives a monthly payment for each beneficiary who resides in the state, and here is where the fraud and waste lives. For example, an individual in Florida applies for and is awarded Medicaid benefits from a vendor. The monthly payments from the state of Florida to the insurance company begin. Next, two months later that beneficiary moves to Georgia and applies for Medicaid in that state and is approved. Florida continues to pay the insurance carrier in Florida and now the insurance carrier in Georgia begins to receive payments from the state of Georgia. The insurance carrier in Floridia continues to receive monthly payments for the remainder of the year without having to pay for medical services. What if the Medicaid provider/vendor is the same company? What happens is that company/vendor now receives monthly payments in both states buy only pays for covered medical care in one state, Georgia.
You might ask, ” but how big could such fraud be?” The answer is very big! The WSJ estimates that Medicaid providers/vendors collected at least $4.3 billion over 3 years for patients who were enrolled , and paid for, in other states. In other words, many of these insurance companies were getting paid twice (by two different) states to provide necessary health insurance coverage for the same beneficiary.
Insurers claim it is up to the states to determine Medicaid eligibility. What a convenient copout by the insurance industry…all the while banking duplicate payments from mulitple states. How easy would be for the insurance industry to check its records to see if it is receiving multiple payments from multiple states to provide coverage for the same beneficiary? I bet it would not be difficult at all but they don’t do it because they are making billions of dollars to look the other way. If individuals were running this scam someone would go to jail for a long time. Will the Department of Justice go after the insurance industry? Don’t hold your breath.
In my home state of Virginia, the big providers of Medicaid include: Aetna Better Health, Anthem HealthKeepers Plus, Molina Healthcare, Sentara Community Plan, and UnitedHealthcare Community Plan. If you work with one of these organizations and this fraud bothers you as much as it bothers me, give us a call. You may be sitting on knowledge of a whistleblower claim that will put an end to this modern day bank robbery.