Le frodi a carico di Medicaid di New York potrebbero ammontare a miliardi di dollari

Usa, Società, Welfare Nyt 05-07-18

Le frodi a carico di Medicaid di New York potrebbero ammontare a miliardi di dollari


creata 40 anni fa per l’assistenza sanitaria di 4,2mn. anziani poveri
di New York,; con i suoi $44,5md., Medicaid è divenuto un motore
economico che nutre una delle maggiori industrie dello Stato, facendo
crescere assieme anche la frode e le spese inutili.

Medicaid dello Stato di NY è il programma di gran lunga più dispendioso degli Usa, con
i suoi $44,5 md. spende molto di più di qualsiasi altro Stato, compresa
la California che copre con Medicaid il 55% di persone in più.
Il budget di Medicaid di NY è maggiore del bilancio complessivo della maggior parte degli Stati, spende quasi il doppio della media nazionale, circa $10 600 per ognuno dei suoi 4,2 mn. di aventi diritto, 1 abitante su 5 di NY.

seguito ad un’investigazione del NYT durata anni, si è scoperto l’abuso
di miliardi di dollari l’anno per il programma Medicaid.]

Nel 1966 il governatore Nelson A. Rockefeller trasformò il programma in legge.

Secondo l’Ufficio per la contabilità federale di Washington, il 10% della spesa federale sanitaria va perso in frodi ed abusi.

capo dell’ufficio di investigazione federale sulle frodi di Medicaid
dello Stato di New York, ora in pensione, ha calcolato che almeno il
10% della spesa è andata in frodi, e il 20-30% in abusi, per un totale
di 40% di spesa discutibile, pari a circa $18md. l’anno.

governo federale condivide il costo di Medicaid con gli Stati. A NY
paga la metà; la capitale dello stato di NY, Albany, suddivide il costo
rimanente con le sue contee e con la città di NY.

Non è un caso che il regolamento del programma sia lasco, medici,
ospedali, società farmaceutiche si sono a lungo opposte al tentativo di
accrescere i controlli di Medicaid. L’industria farmaceutica ha speso
milioni di dollari l’anno per contributi politici ed opera di lobbying
contro i tentativi di limitare i farmaci coperti da Medicaid;
altri Stati hanno risparmiato centinaia di milioni di dollari con tali limitazioni.

All’inizio dell’anno è stato posto un limite legislativo facendo scegliere ai pazienti farmaci generici; l’industria
farmaceutica è però riuscita ad ottenere una scappatoia che consente ai
medici di sostituire il farmaco generico con una marca più costosa.

Nyt 05-07-18

New York Medicaid Fraud May Reach Into Billions

It was created 40 years ago to provide health care for the poorest New Yorkers, offering a lifeline to those who could not afford to have a baby or a heart attack. But in the decades since, New York State’s Medicaid program has also become a $44.5 billion target for the unscrupulous and the opportunistic.

It has drawn dentists like Dr. Dolly Rosen, who within 12 months somehow built the state’s biggest Medicaid dental practice out of a Brooklyn storefront, where she claimed to have performed as many as 991 procedures a day in 2003.
After The New York Times discovered her extraordinary billings through
a computer analysis and questioned the state about them, Dr. Rosen and
two associates were indicted on charges of stealing more than $1 million from the program.

It has drawn van services, intended as medical transportation for patients who cannot walk unaided, that regularly picked up scores of people who walked quite easily when a reporter was watching nearby. In cooperation with medical offices that order these services, the ambulettes typically cost the taxpayers more than $50 a round trip, adding up to $200 million a year. In some cases, the rides that the state paid for may never have taken place.

officials around the state have enrolled tens of thousands of
low-income students in speech therapy without the required evaluation,
garnering more than $1 billion in questionable Medicaid payments for
their districts.
One Buffalo school official sent 4,434 students into speech therapy in a single day without talking to them or reviewing their records, according to federal investigators.

home operators have received substantial salaries and profits from
Medicaid payments, while keeping staffing levels below the national
average. One operator took in $1.5 million in salary and profit in the same year he was fined for neglecting the home’s residents.

has even drawn several criminal rings that duped the program into
paying for an expensive muscle-building drug intended for AIDS patients
that was then diverted to bodybuilders, at a cost of tens of millions.
A single doctor in Brooklyn prescribed $11.5 million worth of the drug,
the vast majority of it after the state said it had tightened rules for covering the drug.

York’s Medicaid program, once a beacon of the Great Society era, has
become so huge, so complex and so lightly policed that it is easily
exploited. Though the program is a vital resource for 4.2 million poor
people who rely on it for their health care, a yearlong investigation
by The Times found that the program has been misspending billions of
dollars annually because of fraud, waste and profiteering.

A computer analysis of several million records obtained under the state
Freedom of Information Law revealed numerous indications of fraud and
abuse that the state had never looked into.

like a honey pot," said John M. Meekins, a former senior Medicaid fraud
prosecutor in Albany who said he grew increasingly disillusioned before
he retired in 2003. "It truly is. That is what they use it for."

health officials denied in interviews that Medicaid was easily cheated,
saying that they were doing an excellent job of overseeing the program.

"This continues to be an area where we
think that we have made substantial progress," said Dennis P. Whalen,
executive deputy commissioner of the State Health Department. "But by
no means are we sitting back and resting on the accomplishments that we
have made."

Nonetheless, after being
informed of The Times’s findings, the Republican majority in the State
Senate began a push recently to overhaul the system intended to protect
Medicaid, which has been sharply reduced
even as Gov. George E. Pataki and lawmakers have nearly doubled the program’s budget over the last decade. The Democratic majority in the Assembly has remained on the sidelines. So has Mr. Pataki.

York’s Medicaid program is by far the most expensive and most generous
in the nation. It spends far more – now $44.5 billion annually – than
that of any other state, even California, whose Medicaid program covers
about 55 percent more people. New York’s Medicaid budget is larger than
most states’ entire budgets, and it spends nearly twice the national
average – roughly $10,600, more than any other state – on each of its
4.2 million recipients, one in every five New Yorkers.
generosity was born of good intentions when Gov. Nelson A. Rockefeller
signed the program into law in 1966, following the state’s tradition of
creating big antipoverty programs.
Medicaid has become far more than the child of that altruism, having
morphed into an economic engine that fuels one of the state’s biggest
industries, leaving fraud and unnecessary spending to grow in its wake.

There are no precise estimates for the
cost to the state’s program. Officials who have spent their careers
chasing unscrupulous doctors and other providers in New York Medicaid
say the losses to taxpayers here are probably higher than typical
estimates of overall health care fraud. The Government
Accountability Office in Washington and others have estimated that 10
percent of all health care spending nationally is lost to "fraud and

James Mehmet, who retired in 2001 as chief state investigator of Medicaid fraud and abuse in New York City, said he and his colleagues believed that at
least 10 percent of state Medicaid dollars were spent on fraudulent
claims, while 20 or 30 percent more were siphoned off by what they
termed abuse
, meaning unnecessary spending that might not be criminal. "So
we’re talking about 40 percent of all claims are questionable," Mr.
Mehmet said – an amount that would approach $18 billion a year.

Despite the debate, and the enormous sums at stake, Albany
has never formally studied how much of the huge government investment
in Medicaid is lost to criminal activity and abuse.

their part, federal auditors have made New York a leading target for
inspection as Washington has begun to crack down on Medicaid spending
abuses. The federal government shares the cost of Medicaid
with the states. In New York, it pays half the bill; Albany splits the
rest of the cost with its counties and New York City.

The lax regulation of the program did not come about by chance. Doctors,
hospitals, health care unions and drug companies have long resisted
attempts to increase the policing of Medicaid. The pharmaceutical
industry, which has spent millions of dollars annually on political
contributions and lobbying in Albany, has defeated several attempts to
limit the drugs covered by Medicaid; other states have saved hundreds
of millions of dollars annually with such restrictions.
this year, after the Legislature agreed to impose such a limit and
steer patients to generic drugs, the industry won a major loophole that
allowed any doctor to substitute a higher-priced brand name with a
simple phone call to the state.
Governor Pataki would not be interviewed about Medicaid for this article, and his aides referred questions to the State Department of Health, which is part of his administration. The health commissioner, Dr. Antonia C. Novello, also declined to be interviewed.

In defending the department’s performance, Mr.
Whalen, the executive deputy commissioner, said it had saved $9.3
billion in recent years through investigations of providers, a new
computer system and other measures.

repeatedly to provide an in-depth explanation of their claim of major
savings or for any state records or other documentation to back up the
figures, department officials would not supply any.

Times investigation drew upon interviews with scores of current and
former officials and health-care providers, including several former
investigators who say they left the state disillusioned about its
commitment to fighting fraud. A review of thousands of pages of
state, federal and local records turned up repeated examples of cost
savings and waste reduction used by the federal government and other
states, but not by New York.

investigation found audits on Medicaid spending that were brushed
aside, and reports on waste that appear to have been shelved.

There have been multiple warnings from watchdog agencies in New York
and in Washington that indicate that the program is becoming
increasingly porous. Prosecutors said state regulators had all but lost
interest in bringing Medicaid thieves to justice, preferring instead to
focus on recouping money through a few civil cases that have little
deterrent value. [… seguono lunghi dettagli di abusi]

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