Know of any Medicaid fraud? Bill would allow Mainers to sue bilkers

AUGUSTA, Maine — A proposed bill would enable Mainers who believe a Medicaid provider or recipient is defrauding the program to sue them to recover money for the state and get a cash award from the court for filing the lawsuit.

“Other states have this plus the federal government has it,” said Rep. Jeffery Gifford, R-Lincoln, sponsor of the bill. “It’s a bill I felt was needed to be put in.”

He said allowing a citizen to take legal action to stop fraud has a long history. He said the measure would be one more tool to stop fraud in the huge Medicaid program.

In Maine, the Medicaid program is called MaineCare. The federal government pays for roughly two-thirds of the program and a third is paid by the state.

“This gives the citizens of the state of Maine a right to file against a fraudulent claim, if they know of it, or they can go to the attorney general and say I believe there are people doing this fraudulently, and turn it over to the attorney general but if the attorney general decides not to pursuit it, the individual party can do it,” Gifford said.

He said it could be expensive to successfully pursue a lawsuit that proves fraud and not just a mistake so it is appropriate that a private individual be able to not only recover costs of a lawsuit but also give a judge the ability to reward the individual for their action.

Gifford said the bill seeks to establish safeguards to make sure the measure is not abused. He is confident the measure will be reworked if needed by the Legislature’s Judiciary Committee to make sure there are adequate safeguards against misuse of the proposal.

“I am sure the proper checks and balances will be in there,” he said.

The measure is drawing support from the Maine Equal Justice Partners, a low-income advocacy group. Robyn Merrill said the measure will provide a useful tool to go after provider fraud, which she says is where there are significant savings to be found.

“We think this is a good bill,” she said. “It goes after fraud in the Medicaid system, and we know there is fraud.”

Merrill, a policy analyst with the group, said there are ways to improve the bill as submitted. For example she said the bill is limited to false claims in the Medicaid program and there are other programs that could benefit from the ability of citizens being able to file a lawsuit to stop fraud.

“There are also some tweaks that could be done to the language that would allow the state to take advantage of a 10 percent bonus allowed in federal law,” she said.

Merrill said the federal government has a similar measure that allows a citizen to file a lawsuit when they believe there is fraud being committed.

The proposal also includes provisions to protect whistle-blowers in government agencies and private companies who use the law to file lawsuits against people or providers they believe are defrauding the Medicaid system. For example, a provider cannot fire the person making the claim against them and if the claim is found true, the employee can get twice any back wages plus interest and additional compensation if found warranted by the court.

“There is also a piece that discourages frivolous claims,” she said. “People can be held accountable if they bring claims they know are not true.”

Gifford said he introduced the legislation because he has heard from constituents for years about this person or that provider cheating the Medicaid system.

“Over the years I have heard numerous people, while I have been campaigning and what not pull you aside and say I know that this person is doing this and this person is doing that,” he said.

Dan Billings, Gov. Paul LePage’s chief legal counsel, said the administration has not taken a position on the legislation. He did write in an email that the administration “is open to the idea.”

In 2007, a similar bill was killed by the Legislature’s Human Services Committee. This measure has been referred to the Legislature’s Judiciary Committee, but a public hearing has not yet been scheduled.