FIGHTING FRAUD
By CHARLES J. HYNES, NY POST, August 23, 2005

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IT is disheartening to learn that - 30 years after New York state was rocked by a scandal in the nursing-home industry - the state Medicaid Fraud Control Unit is underfunded and the state Health Department is unable to stem the losses from fraudulent claims.

Unless our leaders in Albany take the necessary steps to strengthen the existing enforcement mechanisms, the cycle of scandal in the Medicaid program is bound to repeat itself.

In 1975, Gov. Hugh Carey and Attorney General Louis J. Lefkowitz established the first special prosecutor's office inthe country to fight Medicaid fraud and abuse. New York's Medicaid program was in a shambles, thanks to the smallnumber of auditors assigned by the state to audit the books and records of health-care providers and the total absence of any tough lawenforcement initiatives to attack fraud and abuse.

As the first Special Prosecutor for Health and Social Services, I developed a team concept for investigating Medicaid fraud. Prosecutors, investigators and auditors worked in tandem to uncover fraud and to bring the cases to trial.

By 1977, the model was so successful that I, and colleagues from other states, convinced Congress to provide federal reimbursement to states that established Medicaid Fraud Control Units.

The reimbursement was based on the simple premise that fraud units would pay for themselves by preventing abuse and recovering misspent monies. The initial reimbursement was set at 90 percent for the first three years and has remained at 75 percent since then. Medicaid-fraud units now exist in 48 states and the District of Columbia.

Recently, in response to articles detailing massive fraud in the state Medicaid program, proposals have been madeto defer Medicaid prosecutions to local prosecutors if cases are not brought within a specified time period or tocreate an Inspector General for Medicaid fraud. I believe that these proposals are misguided and will not prevent fraud or lead to the recovery of more monies.

Medicaid-fraud prosecutions require long, complex investigations. Establishing that a provider has submittedfraudulent billings involves examining many documents and interviewing many witnesses.

Local prosecutors aren't equipped to handle these time-consuming probes: They need to focus their resources onprotecting public safety. Their priorities are homicides, sex crimes, drug offenses, gun trafficking, hate crimes, domestic violence, drunken driving, robberies and burglaries.

Creating an Inspector General for Medicaid fraud will simply add another layer to the already complicated Medicaidbureaucracy. Traditionally, inspectors general are charged with investigating corruption and misconduct within theirown agencies - and turn over their findings to a prosecutor's office to institute criminal proceedings. They're notequipped to conduct complex criminal investigations.

The only solution to preventing another fullscale scandal in the Medicaid program is to provide adequate funding tothe Medicaid Fraud Control Unit that was created for the express purpose of fighting fraud and abuse. It alone hasthe years of experience and the expertise in conducting the time-consuming investigations needed to root out corruption in the Medicaid program. It alone has statewide jurisdiction to investigate providers who operate in morethan one county.

Most important of all, only the Medicaid Fraud Control Unit is eligible to receive 75 percent federal reimbursement forits crime-fighting efforts.

Officials in Albany, instead of paring the budget of the Medicaid Fraud Control Unit, should give it the funds it needs to get the job done. Before another major scandal erupts, Albany must strengthen the Medicaid Fraud ControlUnit and not undercut its mission by creating another agency or deferring cases to local prosecutors.

Charles J. Hynes, now the Brooklyn DA, was the first special state prosecutor in charge of the Medicaid Fraud Control Unit.

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