MEDICAID FRAUD CRACKDOWN: Doctor claims his innocence, stops seeing Medicaid patients
WILMINGTON, NC (WECT) – Thousands and thousands of dollars are paid each year to people who provide Medicaid services in our region.
North Carolina is in the midst of a Medicaid fraud crackdown, and has begun identifying and prosecuting suspected cases of Medicaid fraud. Last year, the NC Attorney General recovered almost $100 million from suspected Medicaid abusers through dozens of criminal convictions and civil settlements.
In a special report, WECT's Ann McAdams explained how some of those payments are questioned and ultimately flagged for suspicion.
The state has obtained criminal convictions against some Medicaid fraudsters, while others are under review.
Dr. Tom Matthew is one of those providers and says he's done nothing wrong. In fact, he says it's the worst thing that has ever happened in his professional career.
"We have been fine, upstanding providers of care in our community for the past eight years, but we have been lumped with people who are actually, truly doing Medicaid fraud," said Matthew.
After reviewing a sampling of the charts from Trinity Wellness Center, third party auditors working for Medicaid said they found problems – including a lack of documentation for the patients' specific treatment plans and a failure to sign medical charts within 24 hours of seeing a patient.
"People who came to our office from Medicaid and looked through our charts saw no evidence of fraud," said Matthew. "It was only when our charts were sent to a third party reviewer, who has no association directly with Medicaid, that problems with our records, and I say 'problems' loosely were found."
The state initially said Matthew's practice, which has a dozen other providers working under him, overbilled Medicaid by $368,000 over a two-year period. That amount was reduced after Matthew's attorney appealed. He argues the third party auditor had a financial incentive to find problems.
"They are paid a percentage of the amount that they say Dr. Matthew's practice should refund," explained Matthew's attorney Steve Coggins. "When there is no question that the services he rendered were effective, medically necessary and cost efficient. It is wrong."
State Medicaid Director Carol Steckel says regulating Medicaid billing and auditing accounts to identify fraud is a balancing act.
"You want to make sure you are not running the good providers out by making a system that's so onerous that they can't do business, and it's just too much trouble to take Medicaid recipients," explained Steckel.
For now, that's exactly the conclusion Matthew has reached. He stopped seeing Medicaid patients four months ago.
Despite his desire not to discriminate against patients based on their insurance type, Matthew and his attorney agree the practice cannot afford the liability of another Medicaid audit.
"As a lawyer, it is very difficult for me to give any assurance to any health care provider that they would not be subjected to the same thing," said Coggins. "That's how arbitrary I see it."
Matthew and his attorney met with Medicaid regulators on Friday in an effort to resolve this matter. Coggins said they were given the chance to explain why all of the hours billed to Medicaid were appropriate.
He is cautiously optimistic that Medicaid will drop their order that Matthew has to repay money to the state.
Copyright 2013 WECT. All rights reserved.