Entries in Medicaid (3)


Patient Whistleblower Exposes $150 Million Medicaid Fraud

Ingram Publishing/Thinkstock(WASHINGTON) -- In a real-life David versus Goliath story, a 63-year-old wheelchair-bound Medicaid patient took on the multi-billion-dollar healthcare giant Maxim Healthcare. And he won.

On Wednesday the House Oversight Committee heard the saga of how Richard West exposed Maxim’s widespread Medicaid fraud and helped government officials reclaim millions for the cash-strapped program.

“This [fraud] is wholly unacceptable,” said Rep. Trey Gowdy, R-S.C., “This is why people have lost trust in the institutions of government and why our fellow citizens have so little trust that we are spending their money as carefully as we would spend our own.”

Richard West is in a wheelchair, uses a ventilator and needs oxygen.  He also needs Medicaid so he can stay at home while getting care.

In March of 2003, West started receiving that in-home care but in September of 2004 New Jersey state officials suspended his Medicaid benefits, claiming he had exceeded his monthly cap.

West determined that his healthcare provider, Maxim, had billed Medicaid for 735 hours of nursing care he never received -- fraudulent charges that amounted to more than $20,000.

Armed with the evidence, West complained to New Jersey officials.  They ignored him. Next he went to Medicaid, then to a social worker, but the social worker did nothing. West then found an attorney who filed a whistleblower lawsuit under the False Claims Act and that triggered an investigation of Maxim.

“Somebody decided to make a profit on my disability and rip off the government,” West, also a Vietnam War veteran, told the committee. “That was wrong and the right thing for me to do was expose it.”

Today, seven years later, Gary Cantrell, a top government investigator in the Health and Human Service’s Inspector General’s office, told Congress that West is the reason Maxim Healthcare got caught and recently agreed to pay more than $150 million to, “resolve civil and criminal charges,” the “largest ever involving home healthcare services.”

Nine people -- eight former Maxim employees, including three senior managers and the parent of a former Maxim patient -- have pleaded guilty to felony charges for committing fraud, Cantrell testified.

Under the Whistleblower Protection Act, West will receive $14.8 million from the fine Maxim will pay.

In fiscal year 2010, whistleblowers like West helped recover $2.39 billion lost to fraud, according to a Taxpayers Against Fraud report cited in West’s attorney’s testimony. Gowdy said as much as one-fifth of the money Medicaid spends is wasted on fraud.

A provision of the Affordable Care Act provides an additional $350 million over the next decade to help fight fraud, resources Rep. Elijah Cummings, D-Md., said were necessary to prevent cases like West’s.

“When we invest in fraud prevention government spending more than pays for itself,” Cummings said. “That is one reason why repealing the Affordable Care Act and cutting Medicaid’s enforcement budget would be very short sighted and indeed counter-productive.”

Copyright 2011 ABC News Radio


Obama: Social Security, Veterans, Medicaid Checks at Risk

ABC News(WASHINGTON) -- The White House warned Tuesday that millions of Americans might not receive federal benefits checks if both sides can’t reach a deal to raise the nation’s debt limit by Aug. 2.

"We cannot guarantee -- if there were a default -- that any specific bill would be paid,” White House spokesman Jay Carney said, seeking to leverage public pressure on negotiators from both sides who are headed back to the White House this afternoon.

President Obama also raised the specter of short-changing recipients of federal benefits, telling CBS’s Scott Pelly in an interview that "there may simply not be the money in the coffers to do it.”

More than 80 million Americans who receive benefits payments from the government each month could be at risk, the Treasury Department said.  Most of those checks cover Social Security recipients, veterans and civil service retirees.

On Aug. 3, the Treasury is scheduled to make a $23 billion payout of Social Security benefits, a spokeswoman said.  Obama suggested Tuesday that payout could be at risk.

“We no longer have the authority to borrow money if we don’t raise the debt ceiling,” Carney said. “As you know we have obligations that exceed the money we take in.”

Neither the Social Security Administration nor the Treasury Department would comment on the default scenario or how the government would prioritize payments when faced with limited funds.

“That’s the kind of choice nobody want the United States of America to make,” Carney said.  

Copyright 2011 ABC News Radio


Medicare and Social Security Will Run out Sooner Than Thought

Creatas Images/Thinkstock(WASHINGTON) -- The country's benefit programs for the elderly, Medicare and Social Security, will be exhausted sooner than thought due to the economic downturn, The Social Security and Medicare Boards of Trustees said Friday.

Medicare's Hospital Insurance Fund is projected to exhaust its funds in 2024, five years sooner than last year's estimate, and Social Security will be exhausted in 2036, a year earlier than previously thought, the trustees announced.

"Social Security and Medicare benefits are secure today, but reform will be needed so they will be there for current and future retirees," Treasury Secretary Tim Geithner told reporters at a Treasury Department news conference.

Geithner said the report underscores "the need to act sooner rather than later" to make reforms to entitlement programs. 

The report also indicates that Social Security ran a deficit last year for the first time since 1983, and it's projected to run deficits going forward. 

The funds won't go totally bankrupt by the years the trustees projected they would be exhausted, but the programs will no longer be able to pay full benefits.  Social Security would pay out roughly 75 percent of benefits through 2085, Medicare 90 percent in 2024. 

The trustees think the health care overhaul signed by President Obama has given Medicare a longer life.  Health and Human Services Secretary Kathleen Sebelius said there's no question the health care law has strengthened Medicare.  She said the change in the projection for Medicare's Hospital Insurance Fund was due in large part to lower payroll tax revenues caused by the slower than expected economic recovery. But, Sebelius said, "Having the Affordable Health Care Act in place is the main reason those projections aren't worse." 

Copyright 2011 ABC News Radio

ABC News Radio