Millions in Fraud Missing From North Carolina Medicaid Expansion Debate

Every major North Carolina Democrat, including Governor Roy Cooper, is focused on pushing for the expansion of Medicaid.

Cooper included Medicaid expansion in his budget and in his State of the State speech. In both instances, the tax hit to North Carolinians went unaddressed by Cooper but not by state lawmakers.

“Governor Cooper is pushing this idea that his Medicaid expansion proposal is revenue-neutral to the state, but that idea is just not based in reality,” said Senate Leader Phil Berger (R-Rockingham) in a press release. “There is no such thing as ‘free’ money, someone always has to pay. In this case, it’s the taxpayers in the private insurance market who at the end of the day will pay the price of this new tax to fund expansion.”

Part of the argument to expand is a ‘but the other states are doing it’ argument. As of February 2019, 36 have expanded Medicaid and 14, including North Carolina, have not.

What the current debate on the topic has left out is the millions of Medicaid fraud cases each year.

According to the North Carolina Department of Justice, settlements in Medicaid fraud cases have totaled over $65.5 million just in the last two years.

“Since January 1, 2017, MID has had 37 convictions, 36 settlements and 1 civil judgment. The total amount of these convictions/settlements in that time period is $65,590,323.63,” Laura Brewer, the Communications Director for the North Carolina Department of Justice, said in an email.

A search for Medicaid in the North Carolina Department of Justice’s news releases pulls up 4 pages of results. The most recent Medicaid press release details a case of the owner of a Durham mental health company who was hit with a conviction for $4 million in fraudulent Medicaid payments and who was sentenced to 5 years.

Many of the Medicaid fraud cases are national, led the U.S. Department of Justice, and have state-level settlement awards.

National cases include the $337 Million in false billing uncovered as part of national fraud take-down campaign and a $260 million global settlement involving two Charlotte Hospitals.

Both the U.S. Department of Justice, the North Carolina Department of Justice, and various U.S. district courts have played roles in attempting to recover funds in Medicaid fraud schemes.

In February, the Eastern District for North Carolina announced that in the fiscal year 2018, their office had collected $13 Million in civil and criminal cases.

Of that $13 million collected, “$1.7 million was recovered for the Health and Human Services’ Center for Medicare & Medicaid Services and for the North Carolina Medicaid Program.”

Like most government programs, fraud has been around as long as any given program has. Medicaid is no exception.

A 2015 report by the Office of the Inspector General (OIG) for the U.S. Department of Health and Human Services showed that Medicaid fraud and Medicare was costing taxpayers billions each year.

One of the overall findings in the report was that the sponsors, the Centers for Medicare and Medicaid Services, did not do a good job detecting or protecting against fraud.

The OIG report states that as of May 2015, the department had “540 pending complaints cases involving Part D, a 134-percent increase in the last 5 years.”

The report also states that the increase in the casework “demonstrates the continued vulnerability of the Part D program to widespread fraud. This fraud could be mitigated or avoided through better oversight.”

Other key details include:

• In 2009 Part D inappropriately paid $25 million for Schedule II drugs billed as refills.
• Medicare Part D paid out $1.2 billion in claims that had invalid prescriber identifiers and $20.6 million was paid out for Schedule II drug claims with invalid prescribers in 2007.
• CMS paid approximately $3.6 million on behalf of deceased beneficiaries between 2006 and 2007.

While ignoring Medicaid fraud entirely, Cooper and state Democrats have also claimed Medicaid expansion will “bring $4 billion into North Carolina’s economy, creating an estimated 40,000 jobs and providing more affordable health care for 500,000 people.”

Those job figures are refuted by a 2017 study conducted by a Duke University researcher which says the expansion will actually eliminate more jobs than it creates.

The study also says access to care for highly vulnerable individuals who are already enrolled in Medicaid will be drastically reduced, that expansion is unlikely to save lives, is unaffordable in the long run and that it’s “current financing structure encourages fiscal irresponsibility.”

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A.P. Dillon is the North Carolina Bureau Chief for The Tennesee Star and a reporter at Battleground State News. Follow A.P. Dillon on Twitter. Email Tips to [email protected].