WRAL Investigates

New tool tracks NC Medicaid fraud: 'We will come after you'

Posted May 21, 2012

— 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.

Eunice Ngumba-Gatabaki New tool flags 200 Medicaid providers for possible fraud

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.


Read more WRAL Investigates stories or contact the WRAL Investigates team.

153 Comments

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  • JustOneGodLessThanU May 24, 11:38 a.m.

    sceeter said, “I am on Food Stamps. My daughter, 16, is on Medicaid...Have worked, more on than off, since I was 15, I'm 45”

    There are people here, right now on GOLO, who would take away every penny that you get in gov’t assistance. They don’t care about anyone but themselves.

    That said, you need to get a job and support yourself and your family as BEST and HARD as you can. Work at working!

    We all, always, lead by example and your child is watching every move & decision that you make. This is not a normal time for you and you may need to swallow hard and do jobs that you normally would not. This is honorable.

  • ealexandriablake May 22, 5:24 p.m.

    what part of working did you not read in my post; how am i not providing for my child when have a full time job and choose to continue my education part time; for all you know my child's father could be dead.

  • ealexandriablake May 22, 5:12 p.m.

    in response to my post I WORK 40+ HOURS A WEEK AT A BANK I AM PUTTING MYSELF THROUGH GRAD SCHOOL THE SAME SYSTEM I AM USING I PUT INTO PLEASE MY POST IN ITS ENTIRETY BEFORE RESPONDING THANKS!

  • storchheim May 22, 5:10 p.m.

    No, ealex, YOU look in the mirror for a change. I am so sick of blacks telling everyone else to look in the mirror when they choose to continue living off everyone else because they don't want to provide for their own kids. YOU had that baby out of wedlock. YOU are choosing school instead of providing for him. Not only look in the mirror, but the next time you're buying food with our money, turn around, look at US, and say "Thank you".

    How dare you take our money and tell us to be ashamed!

  • aetius476 May 22, 5:01 p.m.

    "Obama care has nothing to do with this article." - andy2

    Andy, it has EVERYTHING to do with this article! A huge part of Obamacare is the massive expansion of Medicaid. the eligible enrollment will expand by over 33% by 2014. Obamacare will make more services available through Mediciad to more people and loosen eligibility requirements.

    Obamacare will expand the already fraud ridden federal goverment helathcare entitlements exponentially. We can't even police the current system.

    do a little research before you post attacks on others...

  • andy2 May 22, 4:47 p.m.

    The ignorance displayed by lessismore and muggs is frightening. Obama care has nothing to do with this article. Medicaid is 100% funded by the tax payer. The number of voters on medicaid do not out number voters not on medicaid. Please take a moment and research the number of Americans below the poverty line. In NC it is 25% of families with children below the age of 18 at home. That does not mean they all are on medicaid. It does not show a majority of voters either.

  • ncouterbanks69 May 22, 4:43 p.m.

    I am a black single working mom going to grad school in the fall my son is on Medicaid and WIC. There are people that abuse the system but some use it as a means to get by while they are making a better life for their families. Please take a look in the mirror before making generalizations and condoning negative stereotypes.

    What about those of us that paid for our own school? Paid for our own children? Had children when we could afford it? No pity here, you should be comended for trying to better your life but you need to do it on your dime. I did, what is to say you can not?

  • lessismore May 22, 4:22 p.m.

    If you thing medicaid is corrupt, wait until you see the "mother of all entitlement programs" - Obama Care.

  • lessismore May 22, 4:17 p.m.

    ealexandriablake......it's not my responsibility to support your son, who is on medicaid and WIC, while you finish grad school. You should be working....not going to school. Support your own family. You chose to have children, not me.

  • lessismore May 22, 4:15 p.m.

    It's a shame those on welfare and entitlements can vote because they out number those of us who are working paying their way. We are now the minority with no way out. Greedy politicians know that welfare votes keep them in office and the life style they "deserve", so the working class have no way out. Taxes will go up....welfare and entitlements will go up, union, pensions, gov't workers, will be protected until there is not enough money in the universe to provide for those who "refuse to pay their own way". Then we will be like Greece. Healthcare, medicare, medicaid is strangling the life out of America and our politicians refuse to address the problem, because they want to keep their job.

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