On of the largest areas for Medicaid fraud, waste and abuse is in Targeted Case Management, particularly under the foster care programs.
Reimbursements are submitted by phantom and ineffective children's programming to provide non-existent health care services and/or extremely poor quality services, by persons who are not qualified, to justify the billing of more extreme and unnecessary evasive medical procedures, more readily recognized as defensive medicine.
As there is little or no redress or recourse for children under the auspices of the state who have been harmed by the relevant aforementioned Medicaid fraud scheme, the pattern of practice continues, as does the false claims.
There is no medical malpractice liability in child welfare.
U.S. House Judicial Committee recently addressed the issues of the practices of defensive medicine in regards to Medical Malpractice Liability. Unfortunately, nothing was mentioned regarding States Child Welfare Medicaid Programs.
Turning in-home and in-school treatment of some of Virginia's most troubled kids over to private providers has resulted in ballooning Medicaid costs, overbilling and treatment by unqualified staff.
Many of the hundreds of firms that jumped into the business also treated children who weren't really eligible for service, according to state records, obtained after repeated Freedom of Information Act requests to the Department of Medical Assistance Services.
Many children were not properly assessed. Providers didn't prepare formal treatment plans and didn't keep progress notes. Providers commonly claimed to provide service in improbable circumstances, including lengthy sessions of up to five hours for young children, as well as treatment after 11 p.m. and on holidays, the records show.
"It's very clear some families and children didn't get the services they needed," said Lester Saltzberg, director of licensing at the Department of Behavioral Health and Developmental Services.
It wasn't for a lack of spending by Medicaid — the joint state and federal health care program for the poor and disabled that's been struggling for years with limited funds.
Medicaid's expenditures on the in-home service has grown 250 percent since 2006, to reach $176.5 million, according to data compiled by the House of Delegates' Appropriation Committee. Just last year, as the state began auditing providers, spending rose 20 percent, according to Medicaid's own data.
Spending on the day-treatment service, generally delivered in schools when children are not in mainstream classes, rose by 418 percent, to $144.9 million. Even after auditing started last year, this spending rose 28.5 percent.
An outside auditor's review of 70 providers' 2008 operations identified $14.9 million of questionable payments. The state attorney general's office prosecuted three cases involving more than $4.6 million of fraud.
"Given the number of new providers and the focus on providing services to children in the community, increasing expenditures were expected," said Medicaid spokesman Craig Markva.
He also said the services were overused as some providers misinterpreted who was eligible and what exactly was required of them.
In July, Medicaid started using a firm to check whether particular children actually need the service for authorizing payment. It strengthened requirements for staff qualifications in September, Markva said.
The two services used to be offered through community services boards, the state's local mental health agencies, usually with staff who held master's degrees or had several years of experience.
In a bid to expand the service, the state opened the service up to private firms three years ago — but didn't update regulations, which meant the private firms could legally send people with only high school diplomas to do clinical tasks in homes and schools, said Saltzberg, at the behavioral health department.
At the $70 an hour Medicaid was paying for the two services, the boards were breaking even on the services provided by their professionals.
But the $70 rate looked like a business opportunity in the private sector. Hundreds of firms signed up for the work — 401, up by nearly 200 in the past two years — and many hired staff with minimal qualifications.
And with nobody in state government checking who the companies were serving, the number of children and families in the system rose too — many were children who were more appropriately served with other kinds of outpatient services, for which Medicaid pays public and private providers $46 an hour, Saltzberg said. It's been tough to keep those programs going, financially.
In one case, Denise McCreary, a suburban Richmond provider billed Medicaid for:
A federal judge last fall convicted her of defrauding Medicaid of $601,580 over a 10 month period.
"The aim was to expand access," Saltzberg said. "But if you expand access without looking at how you regulate, there can be unintended consequences."