Review: Medicaid Fraud Unit Referred Just 16 Cases to Attorney General in 3 Years

Sep 28, 2015

AUGUSTA, Maine — Figures released by the Office of the Inspector General of the U.S. Department of Health and Human Services show that over a three-year period, a special Medicaid fraud unit in Maine only sent a handful of criminal referrals to the state attorney general's office.

That has led to criticism from Attorney General Janet Mills and other Democrats.

The office's review found that out of 3,600 cases referred to the attorney general's office over the past three years, only 16 were referred from the Maine Department of Health and Human Services' Medicaid Program Integrity Unit. This is a special unit created to root out cases of welfare fraud.

Attorney General Janet Mills says such referrals are crucial for her office to able to do its job.

"This is a unit that is supposed to be looking for fraud and misuse of funds and in the millions and millions of dollars that go out the door at DHHS to so many, many contractors, there is potential for abuse out there every minute of every day," she says.

State Rep. Drew Gattine of Westbrook, a Democrat who co-chairs the Legislature's Health and Human Services Committee, says the three-year review brings into question whether the state is getting a good return on its investment in the program integrity unit.

"Over the years we have given the department a tremendous amount of additional resources," he says. "People, money, they have new tools that were implemented, some of the technology upgrades they have done over the last three years. It is shocking that we are not seeing some kind of an uptick in these kinds of numbers."

DHHS spokesman David Sorensen says that is because only cases that are likely to be successfully prosecuted have been turned over to the unit.

Over the three years, the attorney general got 540 total referrals from various sources such as law enforcement, whistleblowers and private citizens. Most were not prosecuted.

"We don't refer cases to them that they say are not prosecutable, but you know what, that is going to change in the future," he says. "We're actually going to start referring cases to them formally."

Sorensen says the unit has done a good job of recovering payments that were improperly paid and says the criticism by Mills and Gattine is unwarranted. There is, he says, another way of looking at fraud statistics.

"We have closed out 263 cases and identified over $10 million in recoupments just fiscal year 2015 alone, so this unit is hard at work saving taxpayers money," Sorensen says.

The Office of the Inspector General faulted the attorney general's office for not keeping accurate and complete records, a problem Mills says has been addressed. The office also questioned why some cases sat for more than year without prosecution. Mills says many provider fraud cases are complex and require more investigation than other cases.

"There are a lot of reasons for delays," Mills says. "You can be doing a criminal investigation for several years, over several years before you get all the right evidence you need to go to court."

Gattine says he has been trying to get detailed reports on Medicaid provider fraud for years because that is where most taxpayer money is lost.

The attorney general's Medicaid fraud unit, which focuses on provider fraud, had 19 criminal convictions over the three year period, 28 civil judgments and collected more than $32 million from those cases.