Fired auditors say Medicaid errors remain issue at New York Health Department

http://www.timesunion.com/news/article/Fired-auditors-say-Medicaid-errors-remain-issue-6283448.php

The state terminated its contract with the Research Foundation in 2010, a year after the U.S. Attorneys office in Albany launched its investigation of the workers’ allegations. Five months ago, the civil claim filed by Monks and her colleagues ended with the Research Foundation agreeing to pay $3.75 million to settle the case. For its part, the state Health Department admitted no wrongdoing and was not listed as a defendant, but the Health Department is referenced more than 30 times in the 15-page complaint, which casts the DOH as a co-conspirator with the Research Foundation.

“CDHS got a bum rap,” Monks said. “They took the heat for the Department of Health.”

James Ryan, who quit the unit not long after Monks was fired, was one of the fivewho filed the civil complaint and split more than $800,000, which was their share of the settlement. Ryan, 65, who like Monks was also a longtime state worker, said federal regulators who were monitoring New York’s Medicaid program “were not happy” about their lack of access to information. He said the state’s error rate for Medicaid recipients was higher than 20 percent and the Health Department was “bound and determined to report five percent.”

In a statement Friday, a Health Department spokesperson said: “The NYS DOH was not a party to the qui tam lawsuit. The SUNY Research Foundation was and settled the matter with the federal government. There has been no action brought against NYS DOH alleging any wrongdoing.”

The federal case was not the only False Claims Act case targeting New York’s Medicaid system.

The same year that Monks and her colleagues filed their claim, five state Health Department workers, including a pharmacist, a nurse and a Medicaid fraud investigator, filed a second complaint in U.S. District Court outlining allegations of fraud against Computer Sciences Corporation, a Nevada company that ran New York’s Medicaid management system since 1986, according to court records.

The claim against CSC said the company, by virture of its contract with New York, “accepted the responsibility to screen out fraudulent claims by recipients and providers.”

“During the course of their employment with the New York state Department of Health, relators have uncovered multitudinous instances in which Medicaid benefits were paid to residents of other states, deceased individuals, incarcerated individuals, or to individuals classified as ‘undomiciled’ or using bogus addresses or with invalid social security numbers,” states the complaint, which was filed under seal in July 2010.

The case remained sealed until last October, when a federal judge ordered it opened two days after the U.S. Attorney’s office notified the court that it would not pursue a fraud case against CSC.

A spokesman for U.S. Attorney Richard S. Hartunian declined comment, noting the civil case against CSC remains open. Federal prosecutors told the court they are reserving their right to pursue a case at a later time.

Harvey Brody, one of the claimants against CSC, is an investigator for the state Office of Medicaid Inspector General. For the past three years, he said, the state has paid him a salary even though he has not been allowed to return to work, has no duties, and still receives favorable job reviews annually.

“They were afraid of me and the other relators (complainants) because we found a pattern of false claims,” Brody said. “We had actual evidence, documents … showing that payments were made to people that didn’t receive services. We think it was about $970 million over roughly a three-year period.”

But their federal complaint lost footing after the U.S. Attorney’s office declined to pursue the case, and their former attorney, state Assemblyman Phil Steck, filed papers asking a federal judge to dismiss the lawsuit.

“We don’t have access to the government’s investigation, so I can’t tell you whether the allegations were completely false or just couldn’t be substantiated,” Steck said. “I think from a lawyer’s point of view sometimes you can have enough probable cause to file a lawsuit, but … it turns out you come to the realization that the case cannot be proven.”

Steve Sumner, an attorney in Dallas, represented CSC in the case and said the allegations made by Brody and his colleagues were baseless.

“Those types of allegations were just off-the-charts inaccurate,” Sumner said. “We were in real close contact with the U.S. Attorneys and DOH investigators, and in fact conducted some of the investigation with the government.”

Patricia Pafundi, a Health Department pharmacist who was a complainant in the federal claim against CSC, said that in her work checking prescriptions for accuracy she uncovered numerous instances of fraud, including claims paid to deceased individuals, ineligible recipients, residents of other countries and to pay for forged prescriptions. Abusing the Medicaid system is “like stealing candy from a baby,” she said.

Pafundi said she reported the problems to everyone from former Senate Majority Leader Joseph L. Bruno to U.S. Sen. Kirsten Gillibrand.

“I think that was the most irritating thing is you would report these and nothing would get done and you continue to see it over and over again,” she said. “The reality is every dollar that’s stolen is another dollar that can’t be spent on people who legitimately earned and need health care. … It’s a shame that people aren’t concerned enough to stop what’s going on.”

Filed under: General Problems