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The U.S. Centers for Medicare & Medicaid Services (CMS)’s Medicaid Integrity Group intends to investigate allegations the Human Services Department (HSD) hindered Medicaid fraud and elder abuse investigations by the New Mexico Attorney General’s Medicaid Fraud & Elder Abuse Division, CMS spokeswoman Mary Kahn told The Independent.
“We plan on conducting an inquiry into this situation with the state Medicaid agency,” Kahn said.
HSD and the state Health Department administer New Mexico’s $1 billion Medicaid program.
The Medicaid Fraud Division reported that HSD and the Health Department had withheld, “filtered” and “sanitized” information and documents requested by investigators, hindering numerous investigations. The allegations were made in the Fraud Division’s 2009 annual report to the Inspector General of the U.S. Department of Health and Human Services. But the Inspector General’s office alerted the Medicaid Integrity Group to the 2009 allegations only last week, Kahn said, following inquiries by The Independent.
Similar allegations were also reported in the Fraud Division’s 2008 annual report, The Independent has confirmed.
“We have not heard from the CMS Medicaid Integrity Group, but of course if they contact us we will work with them to address any questions they may have,” HSD Spokeswoman Betina Gonzales McCracken said Monday.
HSD was “surprised by the allegations,” McCracken told The Independent last month.
But the Medicaid Integrity Group was “already aware of similar allegations related to the state’s relationship with its Medicaid Fraud (Division)” in 2008, Kahn said.
Following its May 2008 review of the state’s Medicaid program, the federal Medicaid Integrity Group ordered HSD to prepare a plan to correct violations of several federal regulations, according to a report obtained by The Independent.
“The State is not in compliance with federal regulations related to required disclosure and reporting requirements,” the report states. Among the violations described in the report was HSD’s failure to report fraud to the state Medicaid Fraud Division, “limiting the ability of the (Division) to prosecute fraud cases.”
The report also faulted HSD for failures to screen Medicaid providers for criminal convictions or to verify patients actually received the care for which Medicaid was billed by health care providers.
The HSD is required to track all cases of suspected Medicaid fraud and abuse, but was not doing so at the time of the 2008 review, the report states.
“HSD has implemented the Corrective Action Plan,” McCracken said Monday.
The concerns raised by the Medicaid Integrity Group’s 2008 review were addressed in the Plan and were different from subsequent allegations raised in the Medicaid Fraud Division’s 2009 report, McCracken said.
“We were unaware there were any further issues that needed to be addressed,” she said. “In light of the (Medicaid Fraud Division) report, we will work with the AGs office to address any issues that might still exist.”
On Monday, the state Senate voted to override Governor Bill Richardson’s pocket veto last year of a bill that would require state agencies to share Medicaid and other program data with the Legislative Finance Committee.
The state’s stonewalling of the Attorney General’s Medicaid fraud investigations violates federal regulations, Attorney General’s office spokesman Phillip Sisneros said Friday.
“HSD’s compliance with the federal Program Integrity regulation could be improved,” Sisneros told The Independent. “That regulation requires that (the Fraud Division) has access to any records or information kept by HSD or its contractors and providers.”
Sisneros cited 42 C.F.R. § 455.21, a federal Medicaid regulation requiring states’ cooperation with State Medicaid fraud control units. The regulation requires states to provide fraud investigators with access to any records, information and computerized data kept by the agency or its contractors.
But according to a report by the Attorney General’s Medicaid Fraud & Elder Abuse Division, the state Human Services Department and Health Department have hindered numerous investigations into fraud and elder abuse by refusing to disclose records to investigators.
Human Services Department spokeswoman Betina Gonzales McCracken rejected those allegations earlier this week, claiming investigators had direct access to patient encounter data, describing patient care for which providers charged Medicaid.
“Regarding encounter data, the (Fraud Division) has the same access our Medicaid staff has, and can receive this information directly,” McCracken said.
But Sisneros said McCracken’s claim was “incorrect.”
“(The Fraud Division) does not have direct access to that data,” Sisneros said. “HSD requires the Division’s investigators and attorneys to submit requests for the information to the HSD Medical Assistance Division, which must give authorization…before the data is released. The Division does not have the ability to ascertain whether the data that is received has been filtered in some way.”
Direct access to Medicaid data would be “a significant step forward,” Sisneros said.
Fraud Division Director Elizabeth Staley did not answer emailed questions and was too busy with the legislative session to discuss the allegations, Sisneros said.
McCracken also said earlier this week that the Fraud Division’s allegations had never been raised at monthly inter-agency Medicaid meetings. But minutes from a May 19, 2009 meeting seem to refute that claim, making clear reference to the Fraud Division “having a hard time obtaining some provider agreements (and) files.”
McCracken had initially said there were not any transcripts or meeting minutes for the monthly inter-agency gatherings, but subsequently disclosed summary minutes from six meetings to The Independent — three meetings in 2008 and another three from 2009, the most recent from a meeting held May 19, 2009.
Minutes were not kept from all of the inter-agency meetings, McCracken said of the 18 months for which no meeting minutes were disclosed. Some meetings had been canceled due to holidays and legislative sessions, McCracken added.
