June 20, 2018
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Legislature’s budget offers LePage chance to show he’s serious about Medicaid fraud

Scott Thistle | Sun Journal
Scott Thistle | Sun Journal


Gov. Paul LePage has devoted an inordinate amount of attention to welfare fraud over the past six months. Yet as he has talked about the need to crack down on abuse by welfare recipients, his administration hasn’t taken basic steps until recently to crack down on fraud and improper payments in MaineCare, Maine’s $2.5 billion public health insurance program.

In January, LePage drew attention to what he characterized as welfare fraud by releasing data compiled by the state Department of Health and Human Services showing more than 3,000 electronic benefit transfer, or EBT, transactions made at smoke shops in Maine, nearly 650 transactions made at retail establishments that primarily sell alcohol, plus several transactions at liquor stores and strip clubs over a nearly 36-month time period.

He has now introduced three bills aimed at cracking down on abuse in the welfare system. They would bar use of state-issued EBT cards outside of Maine; prohibit use of benefits on tobacco, alcohol, gambling, lottery tickets and bail; and impose an upfront work-search requirement on applicants for Temporary Assistance for Needy Families.

And while he has refused to put forward a supplemental budget package this winter to keep the state’s budget in balance, the budget package lawmakers are putting together now offers LePage a chance to show he’s serious about reining in fraud in MaineCare, the state’s Medicaid program.

Democratic budget writers have introduced a budget-balancing provision that would implement operational changes suggested by the Office of the State Auditor in a December report about the program integrity unit within DHHS’ audit division. In fact, the report shows that, while LePage has been serious about his fraud-fighting rhetoric, fraud-fighting measures in the state’s Medicaid program have been seriously lacking.

In the report, the state auditor’s office revealed DHHS fell well short of making full use of the surveillance functions included in the $205 million computer system the agency uses to manage MaineCare, the state’s Medicaid program.

“[T]he most valuable of the three tools, Report Generator, is not being utilized for the most essential surveillance activities (large scale data mining, exception processing and data analysis) on a regular basis, if at all,” Pola Buckley, state auditor, wrote in her report.

In other words, because DHHS makes little use of the Report Generator function, its auditing operation is reviewing far too few claims out of the 30 million Medicaid claims made each year for accuracy. As a result, while LePage was talking about the need to crack down on welfare fraud, DHHS wasn’t flagging nearly as many suspicious claims as it likely should have for further review.

In fact, the auditor’s report pointed out that DHHS did make regular use of Report Generator until June 2012 “because management ensured that adequate time was allowed for one specific staff member to perform this level of surveillance on an ongoing basis.” This staff member left DHHS in June 2012, and the employee’s replacement didn’t stick around for long.

“This illustrates the disadvantage of placing sole reliance on a single individual for mission critical activities,” Buckley wrote.

The budget provision being weighed by the Legislature’s budget writers would require DHHS to implement the state auditor’s recommendations: devoting sufficient staff resources to the regular, intensive surveillance that has been lacking at DHHS.

Improper payments represented as much as 9 percent of state Medicaid budgets, or $11 billion, in 2010, according to the Pew Research Center. For Maine, that proportion would amount to $88.5 million in state funds this fiscal year.

In a response to the state auditor’s findings, DHHS officials say they’re working to implement changes that address the auditor’s concerns — including regular, large-scale surveillance of MaineCare claims and assignment of the task to multiple staffers.

While LePage pursues a crackdown of supposed EBT card abuse, he should also show lawmakers he’s serious about more mundane changes within DHHS that are more likely to turn up misspent funds and save the state money.

It’s on LePage to ensure the integrity of MaineCare and to match his actions to his words.


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