Fraud rampant in health network

WASHINGTON (Map, News) - A new audit details the complete failure of the D.C. government to prevent outsiders from ripping off a health care program financed by city taxpayers that is designed to provide a safety net for the city’s poorest.

Thousands of ineligible people may have gained access to the D.C. Healthcare Alliance by skirting any number of gaping loopholes, according to a late draft of the audit obtained by The Examiner.

Among the audit’s specific findings: Eleven District addresses, not including homeless shelters, accounted for 271 Alliance members, and another 216 addresses accounted for 1,866 members. While some may be apartment buildings, the auditor wrote, the numbers raise concern that certain locations are being fraudulently used to gain access to the program.

The investigation also found that 615 residents who should have been moved into Medicaid the moment they turned 65 were left in the alliance unnecessarily long. As of November 2007, there were 166 U.S. citizens in the alliance who had passed their 65th birthday, include 33 who were older than 70.

The audit further reported alliance members whose income exceeded the eligibility threshold, who provided expired documents as proof of residency, and who were already receiving benefits in Maryland.

“There is a risk that applicants may misrepresent facts to obtain eligibility and the misrepresentation may go undetected,” the auditor concluded.

The $129 million alliance is the heart of the District’s safety net, providing free care to those D.C. residents, including illegal immigrants, who are not eligible for other benefit programs such as Medicaid.

The D.C. Income Maintenance Administration is charged with alliance enrollment, which has increased from 34,907 in June 2006 to 46,490 in November 2007.

The agency is “not doing the kind of background investigations necessary to weed out fraud,” said Ward 6 D.C. Councilman Tommy Wells, who has oversight. The District, he said, has not matched the demand for free health care “with adequate controls.”

The alliance costs the District $212.21 per member per month, meaning taxpayers are out $1 million a year for every 400 people who scam it.

Clarence Carter, director of the Department of Human Services, told Wells’ committee Wednesday that the final audit will act as a “road map” to fix the enrollment process. DHS is “prepared to do whatever we have to do to effectively and efficiently determine eligibility,” Carter said.

The findings

» Auditor was unable to confirm the residency of 309 members out of a 360-member sample, and 47 were deemed “questionable.”

» IMA requires “minimal or no documentation” from applicants who claim to be homeless. Of the 360 case sample, 49 were homeless individuals “with no evidence of further investigation.”

» IMA does not verify driver’s licenses, claims of income, confirming letters, addresses, alien registration numbers or value of assets.

mneibauer@dcexaminer.com

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