Report: NC spending more to halt Medicaid fraud than it recovers

Posted November 15, 2016

— A report released Tuesday by the legislature's internal oversight agency recommends changes in how the state's Medicaid program goes after fraud and waste.

The report noted that North Carolina is spending millions of dollars on claim reviews that are not fraudulent, and attorneys aren't able to follow up on many that are. In the 2013-14 fiscal year, for example, the state paid contractors $3.7 million to hunt out fraudulent claims, but the state was able to recover less than $500,000.

One of the reasons for the imbalance is that investigators couldn't pursue some fraud claims in court because they couldn't get enough reliable evidence due to problems with the NCTracks enrollment system. Also, the report noted, it's very difficult to get money back from providers who may have gone out of business or who are willing to go to court.

Meanwhile, health care providers say that the reviews in place take too much time and paperwork and are driving some providers out of the program.

State Medicaid director Dave Richard also said turnover within the agency has slowed its work.

"No question that we had room for improvement. No question we continue to have room for improvement," Richard said. "But we have hired qualified people to work in those leadership roles. Our goal is to make sure this section does the best for the state of North Carolina."

Another issue, he said, is that, when his program finds an overpayment, the state has to repay the federal government its share, regardless of whether the state ever gets any money back.

Lawmakers are expected to recommend changes to the fraud detection program next month.


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  • Jacob Smith Nov 19, 2016
    user avatar

    View quoted thread

    I am sure tere is plenty enough fraud to go around - republican OR democrat. It is just too expensive to try and catch this by looking at ALL the claims - TWICE.

    The only thing that makes sense to to catch the fraud the FIRST time the claim is evaluated BEFORE it is paid to the provider.

    Having a tighter vetting system for provider might help but could chase away the few providers that take the trouble in the first place.

  • Ken Ackerman Nov 16, 2016
    user avatar

    I think this goes back to 2012 when the Republicans took over all three branches of the NC government. They were adamant that all the systems were rampant with fraud and were going to be zealous in tracking down the violators. I think it was all intended as cover for planned cuts rather than any factual evidence. I think Republicans tend to view and look for the worst in people rather than the norm...

  • Donna Dearing Nov 16, 2016
    user avatar

    This has always been a simple answer, but for some reason government will not do it (both on the State and Federal level). Hire an outside company to recover and collect this tax payer money and allow the company to keep a percentage (30%?). This is a win win as I see it. The company makes 30% of all returned monies and the State gets 70% return with no up front expense or overhead. Duh!

  • Dolly Butler Nov 15, 2016
    user avatar

    Sounds like all the noise you heard about Voter Fraud, doesn't it? And, don't forget, it is your TAX DOLLARS that are going toward this wild goose chase. Who are you voting for in State Government? Do they represent the Best of America?

  • Dolly Butler Nov 15, 2016
    user avatar

    Sounds like all that noise about Voter Fraud, doesn't it......Why look for the worst in people?
    and, don't forget, it is our TAX DOLLARS going on this wild goose chase. Who are you voting for in our local State Government? Do they represent the best of America?