Senate Bill 60, sponsored by State Senator Ellen Roberts, and passed with nearly unanimous bipartisan support, will put some teeth into the prosecution of Medicaid fraud across the state. Currently, the Attorney General’s office prosecutes provider fraud. But recipient fraud is handled through the counties, who often lack the personnel to conduct the investigative process.
In an interview with Catherine Strode, Coordinator of the Health Care Advocacy Program, State Senator Roberts said the bill’s main intent is to create a stronger system of tracking Medicaid fraud carried out by both health care providers and benefit recipients.
Why is this bill good for the state of Colorado?
“Because it will give us good information. Currently we don’t have any streamlined system to inform the legislature as to how much it’s occurring, who’s doing it, provider versus recipient. I think we have people out there saying one thing or another as if there’s strong data to back up their claims. When I went after getting that strong data, I couldn’t locate it.”
How will it be implemented?
“Medicaid fraud is handled in two different ways in Colorado. Grantee or recipient fraud is handled through the counties. The Departments of Human Services at the county level, when they see something that they’re concerned about, are to investigate it. If it rises to the level of abuse, then they are to turn it over to District Attorneys to prosecute the case. If it’s provider fraud, a physician or a hospital, then the Attorney General’s office is supposed to investigate and prosecute. So we have a split system which is why we don’t know at the State Legislature who’s doing what. How much Medicaid fraud is occurring? What’s being pursued? What I have heard from folks is there’s wild speculation both in terms of who’s doing it, how much money is involved, and how many people who actually deserve Medicaid benefits are being deprived because money is being filtered off the system by those who aren’t entitled to it.”
Are there statistics on Medicaid fraud in Colorado?
“No. That’s the point. There are some people who say it’s rampant. And yet last fall when I was trying to get a handle on this, nobody could give me accurate numbers. HCPF has data for what they cover but it’s not the state agency’s responsibility to pursue it on the recipient side. The Attorney General’s office has a Medicaid fraud control unit which has several million dollars a year that they recover. But that is only providers, not recipient fraud. What happens at the county level, because often the dollars involved are much smaller, there’s not really a strong pursuit of going after Medicaid fraud because it takes more time and personnel than they think they will actually recover. The way the statute currently reads is that even if a county were to recover Medicaid fraud proceeds, they have to turn it over to the state (the state being Health Care Policy and Financing) so there’s no incentive for the counties to really pursue it because they have to help pay for the District Attorney to actually prosecute. If they recover any money, they don’t even get the cost of prosecution.”
What is the effect you want the implementation of this bill to have?
“With the huge increase in Medicaid eligibility, the system is going to be overwhelmed for awhile, as we have more and more people enrolled both because we at the legislature expanded eligibility but also depending on what’s happening at the federal level. So I just want to make sure that those entitled to receive Medicaid benefits actually get them. That we don’t have a siphoning off of state money to people who aren’t entitled, or are abusing the system, whether they be providers or recipients of the benefits. There’s so much money at stake in Colorado’s Medicaid budget. That’s why I think we need to get to the bottom of this.”