New tool tracks NC Medicaid fraud: 'We will come after you'
Posted May 21, 2012
Raleigh, N.C. — Last year, North Carolina spent about $10 billion on taxpayer-funded Medicaid claims, covering everything from doctors’ bills to mental health care for low-income residents. Spotting scams in all that money has been difficult, until now.
With help from IBM, the state has a new tool to crack down on fraudulent claims, which experts say could make up as much as 2 percent or $200 million each year.
After receiving a tip, the WRAL Investigates team spent weeks analyzing the billing records of one licensed therapist in Wake County whose name was linked to 22,984 hours of therapy last year, even though there are only 8,760 hours in a year.
Billing records show psychologist Eunice Ngumba-Gatabaki worked, on average, 60 hours per day, which cost the state $1.79 million last year. Her daily average increased last June as records show she worked more than 100 hours per day for 17 days.
On June 14, records show she worked 166 hours and provided services for two agencies in six different counties – 2.5 hours each in Orange, Person and Halifax, 5 hours in Cumberland, 75 hours in Wake and 78 hours in Durham. For that one day of work, the state paid $12,290 for her services, according to records.
Although she owns a Wake Forest-based agency, Amani Psychological Services, about two-thirds of Gatabaki's billing went through Rehoboth Counseling & Consulting Agency on Garner Road in Raleigh. Long hours were also billed under her name through N.C. Behavioral Health and Counseling in Fayetteville.
The WRAL Investigates team tried to contact Gatabaki multiple times by phone and email to get an explanation. When she did not respond, the team tracked her down at her house. She drove to a police station and declined to answer any questions.
Later, through an attorney, Gatabaki released a statement about the "excessive billing" under her name.
"With respect to NC Behavioral Health and Counseling Services, Inc., I categorically deny any knowledge of the firm, its principals or agents. I have never contracted or worked for the firm in question," Gatabaki said.
She acknowledged being hired as an independent contractor for Rehoboth Counseling and said she oversaw the provisionally licensed providers.
"In those cases the Agency (was) to submit a bill under my license number. Any other decisions on billing were the responsibility of Rehoboth Counseling and their management," Gatabaki said.
"Upon a cursory review of the documents provided to me by your staff it seems, there may have been some bills inadvertently billed under my provider number that may be attributable to other licensed providers at the Agency," she added.
Gatabaki says she has not been contacted by any local or state officials about any fraudulent activity. However, if that changes, "I am open to cooperation," she said.
The WRAL Investigates team tried to contact Rehoboth Consulting, but a woman there declined to comment and tried to avoid WRAL’s cameras by getting in the passenger side of her car and climbing over to the driver’s seat.
Rehoboth President and CEO Lisa King Hodge later released a statement saying that the agency "understands that this is an ongoing investigation."
"We do not have facts to provide you with a comment," Hodge said. "We are cooperating and participating fully in the investigation process. We have attempted to abide by all state rules and regulations and intend to correct any issues identified."
The WRAL Investigates team tried to contact N.C. Behavioral Health & Counseling for comment but did not get a response.
The state wants answers about the billing as well. The North Carolina Department of Health and Human Services says N.C. Behavioral Health hasn't provided any receipts to support the questionable billing.
The department also sent a letter on May 4 suspending Rehoboth's Medicaid payments, because the state determined that "a credible allegation of fraud exists for which an investigation is pending."
Acting Health and Human Services Secretary Al Delia wouldn’t comment specifically on WRAL Investigates' case, but admitted that rooting out Medicaid fraud was nearly impossible for his agency in the past.
“I think, certainly, it's a reasonable assumption that fraud has been committed for years, not just here but across the country,” he said. “I think with a large and complicated system, there is a calculation that a criminal or potential criminal will make: ‘What are my chances of getting caught?’”
Those chances rose considerably when the state implemented a new fraud detection computer program from IBM, which uses math and statistics to find abnormalities in Medicaid claims. North Carolina is the first and only state in the country using it.
“We think the numbers out of this first run may be as high as $200 million, or close to that, of questionable costs,” Delia said.
IBM anti-fraud solutions leader Shaun Barry says the tool helps point investigators in the right direction. “It tells them where to look … what rocks to look under, if you will,” he said.
With 88 million Medicaid claims coming into the state each year, fraudsters can “take advantage of the volume, the sheer volume, of claims,” Barry said. However, IBM’s software is able to plow through the volume to find problems, such as overcharging.
The No. 1 source for fraud is counseling services, according to Barry.
“As Jesse James used to say, ‘Why do I rob banks? Because that’s where the money is.’ That’s why we analyze particular types of medical specialties, because that's where the money is,” Barry said.
So far, IBM’s tracking tool has flagged about 200 providers for potential problems, and at least 10 cases have been turned over the state Attorney General's Office.
“If you are a provider trying to rip off the system, it's a new day. We will know who you are and we will come after you,” Delia said.