Home Care Recipient: Medicaid Fraud Is Not a Victimless Crime

Health care providers that use fraudulent billing practices can cost Medicaid, Medicare and private health insurers and private long-term care insurers dearly — and, in some cases, interfere with quality of care patients receive.

Two subcommittees at the House Oversight and Government Affairs Committee looked at the effect of provider fraud on a Medicaid patient during a joint hearing convened Wednesday (see video).

Lawmakers heard from Richard West, a New Jersey resident who helped blow the whistle on Medicaid fraud that affected his own health care by filing a “qui tam” lawsuit under the federal False Claims Act (FCA). The suit eventually led to a home health care provider payinga  $130 million civil settlement and $30 million in criminal fines, West testified, according to a written version of his testimony posted on the committee website.

West qualifies for Medicaid help with paying for 16 hours of in-home nursing care per day because he has trouble with very basic activities of daily living (ADL), such as breathing. He depends on both a wheelchair and a ventilator.

In 2004, because, it was later discovered, the provider had been overbilling Medicaid, a state agency told West had exceeded his monthly benefit cap, and that his Medicaid services were being reduced or suspended as a result.

“This preventedme from obtaining needed dental care,” West said.

Later, West said, after he complained about what he was sure was a billing problem, he filed a complaint with state officials and hired a lawyer.

After that, he said, he had trouble getting home health care nurses to come to his house, even when he had a serious viral infection.