State Medicaid may have to pay back $75 million unauthorized use of money for immigrants

OLYMPIA -- A state audit has questioned nearly $1 billion that Washington's Medicaid program spent last year -- including $75 million that may have to be repaid to the federal government because it was used for unauthorized medical services for undocumented aliens.

Undocumented aliens received prenatal care, chemotherapy, kidney transplants and other procedures the federal government prohibits its money from being spent on, the audit released Thursday found.

Medicaid, a joint state and federal program, spent $6.2 billion last year on health services for the state's poor and disabled.

"We found no improvements in the ... controls from previous years," the audit said. "Washington state is providing service to thousands of ineligible clients using federal Medicaid money. The majority of these clients were admitted into the program due to unaddressed significant weaknesses in the department's controls. This is causing the nation's taxpayers to subsidize Washington state's non-compliance."

The U.S. Health and Human Services Department began reviewing Washington's Medicaid spending on undocumented aliens in March, but it has yet to determine how much, if any, federal money should be repaid.

State Medicaid Director Doug Porter said the federal report most likely will recommend policy changes and tighter controls on how the federal money is spent.

"We might owe them money back -- we might not," Porter said. "Largely, the federal government will determine: Did we make a mistake that was an honest mistake that can be corrected? Or were we trying to game the system and rip off more federal money than we were entitled to and we knew it? That largely drives the corrective action."

Porter said he hopes investigators' findings will concur with what he believes are the facts: "We were looking at the regulations and making the best sense out of them as we could."

In that case, Porter said he expects the federal government to clarify its rules instead of issuing sanctions and a demand to repay the money.

Porter said he's skeptical that the government will demand the full $75 million to be repaid.

"We think what's really at risk is something on the order of maybe $8 million or $10 million," Porter said.

State Auditor Brian Sonntag said it's not up to his office to decide how much of the total liability would have to be repaid.

"What we're going to do is identify improper payments. We're going to identify problems in the audit report," Sonntag said. "In the follow-up, the federal government will determine what or how much has to be repaid. ... Ideally, you wouldn't want to be misspending any of these dollars."

Sonntag said he's concerned that most of the 28 findings in this year's audit were flagged before.

"A lot of these issues are repeat issues," Sonntag said. "You've read these in previous audit reports, and here they are again."

But on the upside, Sonntag said the response from the new head of the Department of Social and Health Services was encouraging.

DSHS Secretary Robin Arnold-Williams said she takes the latest audit findings seriously.

Sonntag said Arnold-Williams' attitude and commitment to resolving audit issues was "very refreshing."

Animosity and a lack of cooperation between agency officials and the auditors marked Sonntag's previous Medicaid audit.

Lack a reliable system to identify treatments and services that are not covered by the Medicaid plan.

Spent federal money on services for undocumented aliens. They did not adequately review pharmaceutical claims for fraud and abuse.

Lack adequate internal controls to prevent Medicaid payments to dead people or people using a dead person's Social Security number.

Porter said the findings could be broken down into three main categories: One, the federal government is giving mixed signals in interpreting its own rules; two, DSHS and auditors are interpreting the rules differently; and three, DSHS and the federal government have agreed on an interpretation of the rules and the Auditor's Office is just wrong.

"We just plain disagree on some issues -- and will likely continue to disagree," he said.

Porter and Sonntag agree that the federal investigation will prove useful in at least clearing up conflicting interpretations.

"What we're looking for is the federal government to come in and provide some clarification to DSHS and to our office," Sonntag said. "This was supposed to happen a couple years ago, and we are very encouraged that it will happen now."

Porter said the department is trying to move quickly to address the problems they do agree on.

"If we haven't already started a correction, we will," he said. "We would like to have that done and in place before his next audit commences"

Here's another route through the illegal morass:

All elected officials, in their capacity as fiduciaries of public monies, are required, by law, to be bonded. The express purpose of bonding is to protect the public's money. Each state sets their own regulations. Now, say public funds went missing and the public official failed to get bond coverage; the state would have no way to recover that money other than restitution through a criminal prosecution. If, it is determined a public official broke the law by failing to apply for bond coverage, that could be an actionable offense.

Public entities that mandate bonding include: Municipalities, counties, townships, school districts, ambulance districts, volunteer fire departments, community college districts, public universities, transit authorities, landfills, sewage treatment facilities, public works maintenance facilities, airports.

Concerns here center on instances when elected officials allowed government agencies to misuse tax dollars-----allowing illegal using phony documentation to get government benefits, to vote in elections for public bond issues...........this is an example of fiduciary negligence, and could violate the state's bonding regulations, and the bonding requirements of the carrier.

Now, if a public official with bonding had previous financial problems---perhaps a bankruptcy or a job loss for financial improprieties, etc---that they failed to reveal to bonding agents, that might subject them to legal penalties.

More goodies.....

SEATTLE POST-INTELLIGENCER
http://seattlepi.nwsource.com/local/6420ap_wa_medicaid_audit.html

Thursday, April 27, 2006 · Last updated 7:04 p.m. PT

Medicaid audit questions nearly $1 billion in spending

By CURT WOODWARD
ASSOCIATED PRESS WRITER

OLYMPIA, Wash. -- Washington state's Medicaid program made nearly $1 billion in questionable payments last year, and may have to refund millions of dollars for improperly paying illegal immigrants' medical bills, a state audit said Thursday.

The sweeping review by state Auditor Brian Sonntag also questioned the state Medicaid agency's investigation of some abuse claims and its controls on identity fraud and prescription drugs, including steroids.

Officials with the state Department of Social and Health Services disputed some findings, but said they would work with Sonntag to iron out conflicting rules that govern health care programs.

"We share a common goal of ensuring the proper use of public funds," said Robin Arnold-Williams, the department director.

A yearly probe of Medicaid spending is required under federal law because the federal government splits the program's costs with the states.

The 155-page audit released Thursday covers the state budget year that ended in June 2005. Washington's Medicaid program spent more than $6.2 billion in that period, Sonntag said.

Auditors identified nearly 30 problem areas for the program. The nearly $1 billion in questioned spending includes more than $83 million in payments for thousands of illegal immigrants' medical expenses.

Half of that money came from the federal government, which only allows its share of Medicaid to be spent on undocumented immigrants in emergencies.

The state was paying providers for non-emergency care, including treatments for ingrown toenails, dental care and acne, auditors said.

"This is causing the nation's taxpayers to subsidize Washington state's noncompliance," the audit said.

That total includes up to $32 million in federal money spent on care for pregnant undocumented immigrants, despite an order to limit that care to childbirth. The state may have to refund that money to the federal government, the audit said.

Auditors from the federal inspector general are now performing their own review of the state's Medicaid spending on undocumented immigrants, officials said.

The DSHS, which oversees Medicaid, said it has since improved policies for tracking improper spending. The federal audit should clear up any other policy misunderstandings, the department wrote.

State auditors also reviewed the department's policy for sex-change surgeries, some breast surgeries, and other potentially "elective" procedures. State Medicaid officials said they had paid more than $110,000 for two gender-reassignment surgeries since 2000, and about $12,600 for corrective surgery after a sex-change operation performed in another country.

The agency has since started to deny requests for sex-change surgeries, saying in a statement that it found "other therapies were equally effective, less costly and incur less risk."

Three people have appealed such denials, and the cases are not yet resolved. Three others have placed initial requests for Medicaid coverage of the surgeries, the state said.

Sonntag noted that the latest audit was much smoother to perform than the previous review, which was not completed after auditors said state officials were not cooperating.

"It's not a fight this time, and we both want to be able to look to the feds for some resolution, and I think that's going to happen," he said.

---

On the Net:

Auditor: http://www.sao.wa.gov

State Medicaid agency: http://fortress.wa.gov/dshs/maa/index.html

From the Evergreen Freedom Foundation web site:

2006 PRESS RELEASES

April 27, 2006

$1 Billion in Medicaid Expenses Questioned by the State Auditor
DSHS continues to be plagued by repeat audit findings

OLYMPIA—The State Auditor issued 28 audit findings today concerning the state's administration of the $6.2 billion Medicaid program (state and federal funds). These findings lead State Auditor's Office (SAO) to question nearly $1 billion in costs for the program; 16 percent of all dollars spent.
The auditor also issued 21 audit findings against the Department of Social and Health Services (DSHS). This follows last year's audits in which the State Auditor issued 19 findings against DSHS (14 of which have not been resolved) and 22 audit findings in the state's Medicaid program (18 of which have not been resolved).

Bob Williams, President of the Evergreen Freedom Foundation, released the following comments in response:

"Any repeat audit finding is unacceptable, let alone the news that a majority of the problems identified last year have not been corrected. State officials' failure to follow the law has potentially led to $1 billion in consequences for taxpayers.

"Taxpayers and those individuals actually eligible for assistance pay the price when state officials refuse to enforce eligibility requirements.

"Until the legislature and governor ensure strict consequences exist for state agencies violating the law, we will continue to see year after year of the same audit problems and countless waste of taxpayer dollars.

"As noted by the State Auditor, 'Lack of compliance with federal regulations could jeopardize future federal funding.' This could mean the loss of billions of dollars."

Additional Information
SAO Audit Executive Summary
Medicaid Audit
DSHS Audit
(2005) DSHS fails $6.1 billion Medicaid audit
http://www.effwa.org/main/article.php?article_id=1547&number=56

Spokesmen Review.com
DSHS may owe millions
$1 billion in 'questioned costs' cited

Richard Roesler
Staff writer
April 28, 2006

OLYMPIA – Washington may have to repay up to $32 million in federal funds it spent on medical care for illegal immigrants, state auditors said Thursday, in two reports detailing nearly $1 billion in "questioned costs."

The audits covered the state Department of Social and Health Services and the state's $6.2 billion Medicaid program. DSHS is by far the largest state agency, with 17,000 employees and a budget of about $8 billion a year.

"We're talking a substantial amount of public dollars – federal and state money – and the ability of those dollars to be accounted for," said State Auditor Brian Sonntag.

"The sad thing is the number of repeat violations," said Bob Williams, a former state lawmaker who now heads up the conservative Evergreen Freedom Foundation. "There's no excuse for this."

DSHS officials agreed with some of Sonntag's findings but disputed others. Many of the situations are not as clear-cut as the audits suggest, they said. The agency, they said, is moving quickly to improve its cost controls and fraud detection.

"That gets lost," said state Medicaid director Doug Porter. "The auditor's told to go out and find things that are weaknesses."

Among the audit findings:

•The state is improperly using federal tax dollars to pay for routine medical care for illegal immigrants, when only emergency care should be covered. Of $103 million the state paid to health care providers in fiscal year 2005 for treatment of illegal immigrants, auditors found millions of dollars in billing codes for cosmetic dentistry, eye exams, contraception, carpal tunnel syndrome, ingrown nails, acne and hearing exams.

•State workers are not consistently verifying Social Security numbers for people applying for Medicaid health coverage. "Further," one audit report states, "the Department does not heed federal alerts notifying staff of invalid Social Security numbers."

•The state is paying widely-varying prices for the human growth steroid Somatropin. Auditors say that the state paid from $47.79 to $5,061 per dose, "at the same dose and even the same provider."

•Washington's Aging and Disability Services Administration isn't making sure that complaints of abuse, neglect, financial exploitation and death at residential care facilities for the elderly, disabled or developmentally disabled get investigated according to federal guidelines. In most cases, auditors found, the state relies on the facilities to do their own investigations.

•The state has paid for two people to have sex-change surgery since 2000, with three other people currently appealing the state's denial of their requests to pay for sex changes.

• DSHS doesn't have sufficient safeguards to prevent people from getting state-paid medical care by using a dead person's Social Security number. In Medicaid billings from fiscal year 2005, auditors said they found hundreds of instances of medical bills charged on behalf of dead people.

•DSHS made duplicate payments totaling nearly $117,000 to social service providers.

State Rep. Bill Hinkle, R-Cle Elum, said he wasn't surprised by the findings. Political leaders must find the will, he said, to make tough changes.

"I think it's hilarious that the Democrats want to talk about universal health care when we can't even do Medicaid," said Hinkle. He's calling for creation of a state inspector-general office to police fraud and improper spending.

"(New DSHS head) Robin Arnold-Williams, to her credit, is doing the best she can," said Hinkle. "But she's new, and she's inherited a mess."

Sonntag also praised Arnold-Williams, saying that she's made the agency much more cooperative with his auditors. She's responsive, he said, and aggressive in trying to address problems.

But most of the problems cited by auditors are not as black and white as they sound, DSHS officials said Thursday.

Federal rules, for example, specify that federal dollars can only be spent on medical care for undocumented aliens in medical emergencies. But they don't define well what constitutes an emergency, said Porter. If a roofer, say, falls and breaks his arm, that's clearly an emergency. But, Porter said, it's unclear if it's still an emergency when he goes back six weeks later to have the cast removed.

Of the $32 million in questioned spending, he said, "We think they were services that people desperately needed, and we felt obliged to pay for them. We've erred on the side of trying to be reasonable."

As for the wildly different prices paid for Somatropin, he said, the differences were due to different strengths, packaging and other factors. (The auditor's office, however, disputes this.)

And the sex-change operations? Medicaid is required to pay for "medically necessary" treatment, Porter said. Until about three years ago, sex-change surgery was a covered procedure. But the state now refers people who feel they're the wrong gender to psychotherapy and hormone treatment, which Porter said have proven equally effective treatments. A few people have appealed that decision. The state is resisting, but if they win their cases, Washington will likely have to pay for additional sex-change surgeries.

Contrary to what the audit reports say, state workers do check Social Security numbers for people seeking Medicaid coverage, Porter said. But a federal directive, he said, also prohibits the state from refusing coverage to people who won't provide a number.

Lastly, another DSHS official disputed the audit finding that DSHS isn't ensuring that complaints about residential care – including nursing homes, boarding homes, adult family homes – are investigated properly. Yes, the facilities investigate their own complaints, said quality assurance administrator Sheldon Plumer, with the Aging and Disability Services Administration. But the state reviews those investigations and often requires more information. In about 5 percent of the cases, he said, the state will do its own investigation.

"We analyze their investigation," he said. "We don't just go in and see whether they've done one."
http://www.spokesmanreview.com/tools/story_pf.asp?ID=128323

From soundpolitics.com re WA State:

April 16, 2006
Mrs. Gregoire promotes entitlements for illegal immigrants
Mrs. Gregoire1 objects to a new federal law that would require Medicaid recipients to document citizenship or legal immigration status, the New York Times reports: "Medicaid Hurdle for Immigrants May Hurt Others"

"This provision is misguided and will serve as a barrier to health care for otherwise eligible United States citizens," said [Mrs.] Gregoire of Washington, a Democrat.

Ms. Gregoire said the provision would cause hardship for many older African-Americans who never received birth certificates and for homeless people who did not have ready access to family records.

The article is full of similar dire predictions. But there is exactly one quote based on actual experience:
In Georgia, Medicaid officials began enforcing a similar requirement in January. Dr. Rhonda M. Medows, commissioner of the state's Department of Community Health, said it had not caused serious problems.
One gets the impression that those who advocate for unlimited entitlements to illegal immigrants simply view them as just another bloc of constituents.

hat tip: reader J.W.

1 Joni Balter has never retracted her incorrect report that

State election officials are not aware of a single documented instance where a non-citizen voted in the governor's race.

Posted by Stefan Sharkansky at April 16, 2006 11:27 AM |

Comments:
Gregoire's "career" was built on Fraud. New opportunities for political corruption can only help further her fraudulent occupation of an office to which she was not elected.

Posted by: GregoireNotGov on April 16, 2006 12:27 PM
1 If I went to Asia, Europe, or Latin America and demanded their governments to pay for my healthcare, they would laugh at me and deport me.
2 Gregoire is being her normal goofy self, but what do you expect from someone who mismanaged the AG's office for 12 years?
3 Since to qualify for medicaid or medicare, you need to have a social security card, there is already a paper trail
4 There are other valid records than passports
5 If you did not get a birth certificate, there baptism certificates, military records, driver's licensees, social security records, BIA records, et al.
6 Let's see how many individuals there are without standard documents, before we say the rule is impossible to enforce
7 Just like Jim McDermott fights for our parents who get caught in the Medicare/caid Catch 22 form letters, McDermott and the other Representatives will fight on this issue also.
8 Gregoire's been drinking Ron Sims Sound Transit punch.
9 There are probably not that many individuals in the worse case scenario
10 If Greg Nickels has time to fine residents for not properly sorting their garbage/recyclables, he has time to help valid citizens/residents produce suitable alternative documentation
11 Enuff said

Posted by: Green Lake Mark on April 16, 2006 12:43 PM
http://www.soundpolitics.com/archives/006044.html

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