NCJ Number
62866
Date Published
1978
Length
65 pages
Annotation
THE NEW YORK STATE ATTORNEY GENERAL'S OFFICE ANALYZES THE PRELIMINARY RESULTS AND IMPACT OF ITS INVESTIGATIONS INTO NURSING HOME FRAUD WHICH UNCOVERED OVER $60 MILLION IN OVERSTATED MEDICAID CLAIMS.
Abstract
IN RESPONSE TO SCANDALS INVOLVING NURSING HOME CARE AND MEDICAID FRAUD, THE GOVERNOR OF NEW YORK IN 1975 ESTABLISHED THE OFFICE OF SPECIAL PROSECUTOR FOR NURSING HOMES, HEALTH, AND SOCIAL SERVICES. THIS DEPARTMENT ULTIMATELY DECIDED TO INVESTIGATE 343 PROFIT-MAKING LONG-TERM CARE FACILITIES. THE MAJORITY WERE NURSING HOMES, BUT THE INVESTIGATION WAS EXPANDED TO INCLUDE FACILITIES WHICH OFFERED CARE ON A PERIODIC BASIS AS NEEDED AND FACILITIES WHICH HAD CLOSED DURING THE PREVIOUS 2 YEARS. REIMBURSEMENT CLAIMS SUBMITTED BY EACH FACILITY FROM 1969 THROUGH 1975 WERE REVIEWED. BY DECEMBER 1978, INVESTIGATIONS FOR 258 FACILITIES HAD BEEN COMPLETED, AND AUDITS HAD REVEALED $63 MILLION IN OVERSTATED CLAIMS WHICH COST THE STATE OVER $40 MILLION IN MEDICAID OVERPAYMENTS. ALTHOUGH THE STATE SHOULD BE ABLE TO RECOVER THIS MONEY, THE FRAUD ALSO INCREASED MEDICAID EXPENSES INDIRECTLY BY INFLATING ITEMS USED IN REIMBURSEMENT CLAIMS AND COST CELLINGS APPLIED BY THE STATE. BECAUSE OF DELAYS IN RECOVERING MONIES THROUGH DEPARTMENT OF HEALTH ADMINISTRATIVE PROCESSES, THE SPECIAL PROSECUTOR WAS GIVEN PERMISSION TO INITIATE LEGAL ACTION IN CRIMINAL CASES WHERE RESTITUTION HAD NOT BEEN OBTAINED AND IN CIVIL CASES INVOLVING OVER $25,000 IN OVERPAYMENTS. TO DATE OWNERS AND EMPLOYEES OF OVER 90 FACILITIES HAVE BEEN INDICTED, AND THE CONVICTION RATE HAS BEEN HIGH. SEVERAL TYPES OF MEDICAID FRAUD ARE DESCRIBED, INCLUDING SPECIAL ACCOUNTING MANIPULATIONS. ALSO DISCUSSED IS NEW YORK'S SUCCESSFUL FEDERAL ANTI-FRAUD PROGRAM ESTABLISHED BY THE MEDICARE-MEDICAID FRAUD AND ABUSE BILL OF 1977 WHICH PROVIDES THE DESIGN AND FUNDING FOR INVESTIGATIVE PROGRAMS IN ALL STATES. THIS LEGISLATION WILL ALLOW NEW YORK TO EXPAND ITS INVESTIGATIONS INTO OTHER MEDICAL SERVICES. THE APPENDIXES CONTAIN TEXTS OF STATE LEGISLATION CONCERNING MEDICAID FRAUD, A CHART ILLUSTRATING THE PROGRESS OF NEW YORK'S INVESTIGATIONS, AND A CHART OF RECOVERABLE MEDICAID FUNDS. (MJM)