Medicaid system

These aforementioned incidences and the others like it are all a result of the system becoming lax with monitoring Medicaid activity and “state regulators [losing] interest in bringing Medicaid thieves to justice, preferring instead to focus on recouping money through a few civil cases that have little deterrent value. ” The lapses in the New York Medicaid system, which resulted in the abuse of the system, are all a direct result of the system’s biggest weakness: monitoring.

The New York Medicaid program has become more than an altruistic program designed for New York’s poor – it is now a giant economic engine that fuels one of the state’s biggest industries. This unforeseen transformation left “fraud and unnecessary spending to grow in its wake” (Levy and Luo, 2005, p. 2). This growth did have its advantages such as increased areas of coverage and services, advances in the delivery of holistic care and ease of claims filing and information dissemination through electronic methods.

However, this same expansion has left the system highly vulnerable. With such a wide area of jurisdiction and concern (from pharmaceuticals to public school health services etc. ), surveillance and monitoring becomes complicated. With an electronic messaging and filing system, the system is easily flooded with claims and reports that are most likely automatically processed with very little actual authentication. And as noted in the Times inquiry into the matter: 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 (Levy and Luo, 2005, p. 2). It has become highly evident that the main weakness of the New York State’s Medicaid system is its increased level of bureaucracy and complexity which has left the system nearly impossible to monitor.

As much as opportunistic elements have exploited the weaknesses of the system, the New York Medicaid system does have its strengths that can be nourished to strengthen the system’s defense. One of the biggest strengths associated with the system is also its extensive network. Properly harnessed, the system can be used to police itself. Given the right motivation and incentives, ambulette service providers, for example, could report practitioners who misuse the service and vice versa.

Pharmacies and pharmaceutical companies can raise a red flag on certain practitioners or providers whose prescription activities exhibit questionable sudden spikes in frequency and amount such as in the case with the black market demand for the AIDS drug Serostim. Inquiries on staffing levels and service quality of Medicaid subsidized businesses such as nursing homes should also be conducted frequently in order to asses whether funding is being utilized appropriately.

Furthermore, the New York government and Medicaid officials could also adopt an electronic surveillance of all transactions being entered into the system. As the article shows, even the Times with the aid of a common computer software and knowledge of Medicaid billing processes were able to find questionable practices. Surely, if the New York government invests in the creation of a department whose sole functions are to monitor and analyze the traffic of reimbursement applications being processed by the system and initiate investigative action.

Funding and maintaining such a department would probably cost the government less than $700,000 annually – a figure that is admittedly smaller than being drained of tens of millions annually. In the mean time, to curb the current problem, it is probably in the best interest of the state if the program adopted strategies that have been in use by other states in policing and limiting their Medicaid-related expenses. For example, the program could require doctors to avail of special permits in order to prescribe problem drugs such as Serostim.

After all, “[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” (Levy and Luo, 2005) and New York can benefit from these examples. References Levy, C. J. , and Luo, M. (2005). New York Medicaid fraud may reach into billions. The New York Times, published July 18, 2005 p. 1-8. Retrieved on March 20, 2009 from http://www. nytimes. com/2005/07/18/nyregion/18medicaid. html? pagewanted=8&_r=1

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