State Comptroller Matt Boxer's investigators reviewed five Adult Medical Day Care (AMDC) facilities in Ocean, Essex, Union, Middlesex and Atlantic counties and found problems at every one of them.

State Comptroller Matt Boxer (Governor's Office)

The centers were billing for services they can't prove they provided, for patients they can't prove were ever at their facilities and there are now questions about whether patients at those facilities are receiving proper care.

"We found problems at all five of those facilities particularly in terms of the payments the facilities have sought and received from the Medicaid program," explains Boxer. "It's not often that we look at this many service providers in one industry and find these kinds of problems at all of them."

The AMDC program serves adults who have physical or cognitive impairments but do not require 24-hour inpatient care. In recent years, the state Medicaid program has paid an average of $195 million per year to AMDC facilities as reimbursement for providing medical services and assistance with activities of daily living, such as walking or eating.

Medicaid is funded by taxpayer dollars. The ways in which your money is being wasted could have you scratching your head.

"Our investigators found that Adult Medical Day Care facilities received state and federal Medicaid dollars for services they could not possibly have provideD because they had billed the state for patients who were not even in attendance on the days in question," says Boxer. "At one facility we found the state had been billed daily for more than a month for services provided to an individual who was actually away on vacation that entire time."

Other Findings In The Report

  • A review of 50 pending Medicaid claims made by one AMDC facility found 90 percent of those claims did not have the documentation needed to support reimbursement.
  • At the same facility, investigators also conducted a post-payment review of claims related to 28 people who purportedly attended the facility during the period under review. The facility could not provide any paperwork or documentation at all for six of those individuals.
  • A review of 228 claims at yet another facility found that for 133 of those claims the facility was not able to produce the required patient signature at the facility for the day in question, or required documentation of arrival or departure times recording the patient's attendance.
  • The investigation also uncovered billings for a series of individuals who did not appear to be clinically eligible to participate in the AMDC program or otherwise did not appear to need the program's services.

Medicaid Fraud Director

Medicaid Fraud Division Director Mark Anderson says the state's transition to managed care in the AMDC program presents a prime opportunity to revisit and strengthen current monitoring procedures.

"The fiscal consequences of failure in this regard are significant," explains Anderson. "If the costs to managed care organizations in administering the AMDC program are inflated due to waste and fraud, the state will bear the expense. We need a stronger system of oversight to prevent that from happening."

Asked by one reporter at a late morning press conference if the review reveals a need for a Medicaid Inspector General, Boxer said that's not necessary.

"That's what we are," says Boxer. "We've got this."

One facility has already settled with the state. Boxer is seeking settlements from the other four centers in the amount of $10.2 million.

AMDC Lawyer Responds

The attorney for four of the centers says most of the allegations deal with documentation issues and that the facilities have changed their policies as a result of the investigation.