North Dakota’s Medicaid Fraud Control Unit more than pays for itself; officials want more staff
North Dakota's Medicaid Fraud Unit recovers almost $1.50 for every $1 in state funds, but the team grapples with a backlog of cases.
BISMARCK — North Dakota Attorney General Drew Wrigley is proposing increased staffing of the state’s recently created Medicaid Fraud Control Unit, which has recouped more money than its budget.
The Medicaid Fraud Control Unit — which became the last in the nation when it started in 2019 — so far has recovered $511,000, or nearly 1½ times the almost $350,000 the state has spent on the program, according to state figures.
“The division has proved itself,” said Wrigley, whose office includes the fraud control program. “The value of it is obvious.”
The fraud control unit has a staff of six, including one prosecutor, two Bureau of Criminal Investigation agents and two auditors. Wrigley will ask legislators in the upcoming session, which starts in January, to add three positions, including another lawyer, another BCI investigator and a paralegal.
“It’s kind of a skeletal operation,” he said. “We’re really pleased with what the division has done to this point.”
When the program started, the federal government paid 90% of the cost, with the state picking up 10%. The cost share has since changed, with the federal government paying 75% and the state 25%.
“It’s still a bargain,” Wrigley said.
The Medicaid Fraud Control Unit has secured orders or settlements totaling almost $700,000, although not all of that has yet been recovered, since payments can be spread over several years, said Marina Spahr, an assistant attorney general and the unit’s director.
“It’s absolutely cost-effective,” she said.
Spahr’s team investigates and prosecutes fraudulent Medicaid billing cases, as well as abuse and neglect of those cared for by providers paid by Medicaid.
In June, for example, the unit secured an order requiring a Mandan qualified service provider, who provided in-home services among other assistance, to pay almost $76,000. In August, Spahr prosecuted a certified nursing assistant in Valley City who was convicted of abusing an elderly nursing home resident.
It’s not unusual for an investigation to involve overlapping allegations of fraud and patient abuse, Spahr said.
Because of a high caseload and the complexity of investigations, the office in September imposed a hold on investigations, although it continues to take and review referrals, she said.
“Our cases are really involved,” often requiring examination of thousands of pages of Medicaid claims and other documents, Spahr said.
Since the program’s inception in 2019, the fraud control unit has received 127 tips, resulting in about 50 major cases, not all of which resulted in prosecution, she said.
It’s impossible to know how much Medicaid fraud goes on in North Dakota, Wrigley said.
“You don’t know what you don’t know,” he said. “I can tell you it comes in many forms,” he said, including billing fraud, prescription fraud — such as the diversion of narcotics onto the black market — and care that is lacking in quality or involves outright neglect or abuse.
“The list goes on and on, limited only by the imagination of the people who want to defraud the government,” Wrigley said.
The U.S. Department of Human Services Office of the Inspector General estimates that nationally between 1% and 2% of all Medicaid payments are obtained through fraud, Spahr said.
In North Dakota, Medicaid payments totaled $648 million in 2020, or almost $6.5 million per year, assuming 1% of the billings were fraudulent, she said. “I would expect us to be on the lower end,” Spahr added.
Those who suspect Medicaid fraud or abuse can call the unit at 701-328-5446 or email firstname.lastname@example.org .