Medicaid. Is it being abused?

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Medicaid was a great idea when first introduced to assure that even the very poor could get quality health care. I just wonder when I see someone drive up in a newer car come up to the triage desk in designer clothes and lots of gold jewelry and they are on medicaid. I know of many who are the working middle class who are struggling to pay their own insurance premiums. Why do so many folks get a free ride? Or am I missing something here?

Specializes in Acute Care Psych, DNP Student.

I sense from many of the posts here, that the anger is really about how much those on private insurance have to pay, rather than any actual Medicaid fraud. These are of course separate issues. If this is the case, perhaps some should consider if the problem is the system of healthcare financing in the US, rather than any real or perceived Medicaid fraud.

We spend more total $$$s in the US to cover the lowest percent of citizens of any industrialized nation. The other industrialized nations spend less, cover everyone, and have better stats (infant mortality, life expectancy) to boot.

I hesitate to bring this up, because it can appear like another issue. But I think it is really all part of the same pain as evidenced there in this thread.

Also I have read comments on this thread about how 'they' should just purchase their own coverage. Health insurance is unlike any other product out there. If you have health problems, no matter how much money you are willing to pay, many times you cannot get any company to sell you coverage. I am talking about individual coverage, not employer coverage or HIPAA coverage.

Example, because I have severe asthma I cannot get coverage for less than $1200 per month under HIPAA. Also, many employers are choosing to control their spiraling-out-of-control premiums by excluding from coverage pre-existing conditions for the first 12 months for those who did not have previous coverage. I spoke with a social worker the other day who said many of these folks are ending up on Medicaid, while working (poor) in order to get their meds and tx. Oh, and we are not blameless in the US as citizens. US healthcare financing largly doesn't work because so many people don't pay in premiums when they are healthy and able to pay premiums. It's called adverse selection. Meaning, healthy people skip paying and the sick and responsible pay their insurance premiums.

Really, the only people left with good coverage (even though they gripe about the cost) are those employed by large employers, gov't, and retirees thru medicare.

I was a health insurance broker for many years. I know that the system does not work in the US. Frankly, at this point, I wish every single person who qualifies for Medicaid would go get on it, and use it as they need it, appropriately. Only when the Federal and State budgets are in an epic budgetary crisis (worse than now) will we get anything like a universal solution.

Let's remember, we are talking about people using the services for illness/pain. I know a woman who couldn't bear to apply for Medicaid. Pride. Stigma. She was unemployed and had back pain that she couldn't figure out. She kept trying to hold on and get a job with health insurance, despite being in pain. She died last year of cancer. Tumors on her spine. If she had gotten on Medicaid earlier and gotten treatment she possibly could have made it. Doesn't that put the occasional irritating Medicaid mooch in perspective?

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I sense from many of the posts here, that the anger is really about how much those on private insurance have to pay, rather than any actual Medicaid fraud. These are of course separate issues. If this is the case, perhaps some should consider if the problem is the system of healthcare financing in the US, rather than any real or perceived Medicaid fraud.

We spend more total $$$s in the US to cover the least number of citizens of any industrialized nation. The other industrialized nations spend less, cover everyone, and have better stats (infant mortality, life expectancy) to boot.

I hesitate to bring this up, because it can appear like another issue. But I think it is really all part of the same pain as evidenced there in this thread.

Also I have read comments on this thread about how 'they' should just purchase their own coverage. Health insurance is unlike any other product out there. If you have health problems, no matter how much money you are willing to pay, many times you cannot get any company to sell you coverage. I am talking about individual coverage, not employer coverage or HIPAA coverage.

Example, because I have severe asthma I cannot get coverage for less than $1200 per month under HIPAA. Also, many employers are choosing to control their spiraling-out-of-control premiums by excluding from coverage pre-existing conditions for the first 12 months for those who did not have previous coverage. I spoke with a social worker the other day who said many of these folks are ending up on Medicaid, while working (poor) in order to get their meds and tx. Oh, and we are not blameless in the US as citizens. US healthcare financing largly doesn't work because so many people don't pay in premiums when they are healthy and able to pay premiums. It's called adverse selection. Meaning, healthy people skip paying and the sick and responsible pay their insurance premiums.

Really, the only people left with good coverage (even though they gripe about the cost) are those employed by large employers, gov't, and retirees thru medicare.

I was a health insurance broker for many years. I know that the system does not work in the US. Frankly, at this point, I wish every single person who qualifies for Medicaid would go get on it, and use it as they need it, appropriately. Only when the Federal and State budgets are in an epic budgetary crisis (worse than now) will we get anything like a universal solution.

Let's remember, we are talking about people using the services for illness/pain. I know a woman who couldn't bear to apply for Medicaid. Pride. Stigma. She was unemployed and had back pain that she couldn't figure out. She kept trying to hold on and get a job with health insurance, despite being in pain. She died last year of cancer. Tumors on her spine. If she had gotten on Medicaid earlier and gotten treatment she possibly could have made it. Doesn't that put the occasional irritating Medicaid mooch in perspective?

I have worked in fraud and abuse investigation, for the NYSDOH. I have also worked in public home health, as well as a rehab nurse/case manager for WC/personal liability. I have seen less then 10 out right fraud cases in WC, none in liability, none in home health. I have listened to some of my relatives offer the same claims of seeing someone receive medicaid or welfare that they feel should not but they do nothing about it but complain. Regardless of what some believe, in this country, we are the only industrialized western county where health care is not a right. Where health care cost spiral up and up every year. Where more and more of our middle income families spend more for less coverage. Where medication cost continue to go out of control. Where some deny themselves health care and medication from some warped sense of non-entitlement, who then die.

Until such time this country learns that health care is a rught, we will continue along the same pathetic road we are currently on.

Grannynurse

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Specializes in nursing home, clinic, homehealth.

Yeah, by people who do not really even need it!! A mother can go in and get afdc and automatically get medicaid for the whole family while some do not even need it!! I am a diabetic over here with no assistance with DR's or meds and all those people out there getting medicaid to use for what - because they have a simple cold!!! It p's me off to no extent!!!!!!!!!!:devil: Oh, here in Texas an adult can only get medicaid if they receive cash assistance(AFDC)!!!!!!!!!!!!

Steph

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Specializes in Public Health, DEI.

There is no more AFDC, it is now called TANF- Temporary Assistance for Needy Families. You can't have it for life any more. I agree with whoever it was that said that this all sounds more like it is about anger- either at what is being paid for private insurance premiums, or at not qualifying for public assistance when others do. However, just because things aren't fair doesn't mean someone is committing fraud. The working poor (and in many cases, the middle class, too) should be entitled to the same health care that Medicaid recipients receive. The government should stop discouraging marriage by incentivizing staying poor and unwed. No doubt about those points. Claiming that beneficiaries of the system are committing fraud is blaming the wrong party, IMHO. The big problem is the system itself.

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I was married, had a good job, my own health insurance , a 1 1/2 year old boy, and I was pregnant. Husband became very abusive....had to flee the state and hide out until the custody hearing. I went on assistance and entered the address confidentiality program. The social worker helping me saw my wedding ring and made nasty comments about me having something like that while bieng on assistance. I kept my wedding ring b/c people tend to give my crappy looks for bieng pregnant without having one on. Dammed if you do dammed if you don't. There is no way to make everyone happy...some people get a high from bieng judgemental. I am now in nursing school but my kids still have state insurance. I can't afford it and the deadbeat ex isn't paying like he should. I cannot wait to get of state aid. I need it but the hell that people put you through makes it almost unbearable:dirty looks, s******ing, how can you afford that comments- it takes away your dignity.

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I know someone who is on Medicaid, lives in a rent-assisted apartment, receives day care assistance and receives free school as well. This is all because she had a baby out of wedlock at a young age. The kicker is that her live-boyfriend has his mail sent to his parents house because they would kick her out if they found out he was living there. She works as a waitress and doesn't report her part of her tip money to keep her income down. Then, she walks around wearing designer clothes and Nike Shox shoes at over $100 per pair... This is abuse of the system if I ever saw it, but she doesn't see anything wrong with it!

As others have stated, she would lose all her benefits if she got married, so she chooses not to. The government is providing a strong incentive for girls to have out-of-wedlock babies IMO.

I know other girls of middle class families who go on assistance when they get pregnant- even though their parents could easily afford to help them out. Their parents are the ones who are encouraging it in most cases. Heaven forbid they should have to give up their vacation home or postpone putting a new deck on the house!

My parents were divorced when I was young and my dad took off after running up the credit cards and causing foreclosure on the house. My mother took a full-time job (and later a second job) and my grandparents watched us some days to save on day care expenses. Even when things were tight, we never were on any kind of assistance. My clothes came from JC Penny Outlet or the thrift store and our shoes were from Payless, and I didn't have cable until I lived in the dorms at college. My sister and I had to go to school early in the mornings to use the computer, because we did not have one at home. I feel that my mother set an excellent example for my sister and me. I credit her for my strong work ethic and my ability to live within my means.

I believe in receiving short-term help if you really need it, but many people apply for assistance as a FIRST instead of a LAST option or abuse the system (as in the example above). Medicaid and other forms of aid should be reserved for those who are disabled themselves or have disabled children, those who legitimately cannot work, or for the working poor IMO.

You and I have a lot in common.

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Specializes in Occ health, Med/surg, ER.

I would really like to see all these people who are receiving Medicaid fraudently, really I would.

To be honest with everyone, I am sick and tired of a few complaining about another few and acting like they were the majority. If you feel some one is receiving Medicare, Medicaid, food stamps, public assistance fraudently YOU HAVE THE RESPONSIBILITY TO REPORT IT TO THE APPROPRIATE AUTHORITY. Thar is medicare, medicaid, your public assistance office, your state attorney general. And you don't have to give your name. All you need is the name and address of the suspected person or persons. You can even send a letter in. And while you are at it, take a look at the facility you work for and their /mistakes'. It is funny how they keep making the same one over and over and over-------

Grannynurse

There are many people who scam to get assistance. To be honest, I have seen it a lot. I've seen alot of people cheat, and a lot of people get caught and have to pay it all back. What hurts me though is the kids, its not their fault. When the foodstamps get cut off because of dishonesty from the parents, they can't eat as good and they wonder why.

Many people (esp with kids) need foodstamps and cant get it because of some technicality{sp}, so they scam. Its not right, but it happens. People who receive home medical care are most likely getting assistance on the "legit". I'm sure people that are scamming for public assistance dont have medical personnel coming to their homes everyday where it becomes evident that they receiving assistance fradulently, for example, someone else living there, or not living there.

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You don't have any proof that there is fraud. She may qualify for Medicaid under a waiver program. It is only fraud if she lied about her income on the application, and you haven't told us that any such thing has happened. As for the home visits, that may be something that is covered under your County's public health program. At any rate, it certainly doesn't sound fraudulent. If I was manning the phone of an agency you called and reported this limited information, I'd probably ask you what, exactly, it is that you think should be done.

***************

Do you think the person will tell me how much she declared in an application? Of course not, be realistic! They say that if you have a gut feel, the more reason to believe it that there's soemthing wrong there. She may be in waiver when she first came in this country 7 yrs ago but not able or don't want to update their income. Believe me there's wrong with the situation b/c they can afford to have an SUV, enroll in Bally fitness program, can afford a $1000/mo rent and yet does not pay any medical bill? One time I asked her if she already filed for the income tax, she answered me vaguely, as if she have not filed that her life. I'm fine with people receiving medicaid if they truly deserve it but it so unfair for all people working hard and paying their dues and end up paying for this opportunist medical insurance. That's one of the reason why we are paying more taxes now.

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Any nurse who has worked in the ER can tell you of medicaid abuse. My solution is a ten dollar co-pay for any service that is not a actual classified emergency. Small amount, yet enough to encourage better medical mng. You have to keep it simple. Also as of Jan 1 all medicaid now fall under the medicare drug plans. Too bad those could not have been designed more simpler.

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Specializes in Public Health, DEI.
Do you think the person will tell me how much she declared in an application? Of course not, be realistic! They say that if you have a gut feel, the more reason to believe it that there's soemthing wrong there. She may be in waiver when she first came in this country 7 yrs ago but not able or don't want to update their income. Believe me there's wrong with the situation b/c they can afford to have an SUV, enroll in Bally fitness program, can afford a $1000/mo rent and yet does not pay any medical bill? One time I asked her if she already filed for the income tax, she answered me vaguely, as if she have not filed that her life. I'm fine with people receiving medicaid if they truly deserve it but it so unfair for all people working hard and paying their dues and end up paying for this opportunist medical insurance. That's one of the reason why we are paying more taxes now.

Do I think she answered you truthfully? I have no idea, having never met this person or you. To be perfectly honest, though, if you asked me these questions, I wouldn't bother with vagueness, I'd tell you to mind your own business. You still haven't presented anything to support your allegation that there's fraud here. Maybe there is, but since you have no way of knowing who is paying for all the things you seem to consider luxuries, all you've got is speculation. Good luck getting anyone to take that seriously.

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I honestly don't recall seeing any cases of fraud, but I have seen a lot of cases where Medicaid is abused by people who actually need it. We had one couple who came to the ER once a month for a pregnancy test. She came in around the same time every month and said she was late, having cramps, breast tenderness, mood swings, etc and was sure she was pregnant...no one could convince her that she was expereincing PMS and that her period would probably start in a few days...just like last month. As far as I know, she still isn't pregnant. We also see people who bring their kids in because they didn't eat dinner...once. No other symptoms, just didn't eat the tuna casserole or whatever mom made for dinner. We saw a lot of people who were wanting prescriptions for Tylenol, Benadryl, Fleets, etc because they got them for free if they had a prescription. We checked one patient's medical record because we were concerned about the amount of times she was in seeking post-coital contraception...eleven times in three years...refused the pill, patch, etc because they caused weight gain. We saw patients who came in with scratches and papercuts because they needed band-aids...other similar things.

Unfortunately, most of us never see many of the people who use Medicaid appropriately for just that reason...they don't use it unless they are truly sick...the ones who use it for nonsense are the only ones we see on a regular basis.

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I honestly don't recall seeing any cases of fraud, but I have seen a lot of cases where Medicaid is abused by people who actually need it. We had one couple who came to the ER once a month for a pregnancy test. She came in around the same time every month and said she was late, having cramps, breast tenderness, mood swings, etc and was sure she was pregnant...no one could convince her that she was expereincing PMS and that her period would probably start in a few days...just like last month. As far as I know, she still isn't pregnant. We also see people who bring their kids in because they didn't eat dinner...once. No other symptoms, just didn't eat the tuna casserole or whatever mom made for dinner. We saw a lot of people who were wanting prescriptions for Tylenol, Benadryl, Fleets, etc because they got them for free if they had a prescription. We checked one patient's medical record because we were concerned about the amount of times she was in seeking post-coital contraception...eleven times in three years...refused the pill, patch, etc because they caused weight gain. We saw patients who came in with scratches and papercuts because they needed band-aids...other similar things.

Unfortunately, most of us never see many of the people who use Medicaid appropriately for just that reason...they don't use it unless they are truly sick...the ones who use it for nonsense are the only ones we see on a regular basis.

You know I would really like to see all the patients who abuse Medicaid, truly I would. I have been a nurse since Medicaid came into being. I have worked in ERs, in a large city and some very small ones. And I have never had the time to check the face sheet, let alone know who was paying the bill. As a matter of fact, I've never seen any of the type of patients that I have seen discribed here. I guess they never came into Kings County or Met, or Elmhurst, in New York City. Or for that matter, Englewood, Manatee or Doctors Hospitals here in Florida. Guess I was just unlucky.

Last night I went to the ER because of my asthma. The waiting room was crowded, four with apparent leg injuries, a few kids with runny noses and other aliments. Two women, in my age group, also having trouble breathing. And when I talked to one of the ER nurses, she told me that they had been slammed all of her shift, with kids with temps; broken bones; adults with temps, difficulty breathing, chest pain, r/o strokes. I wonder how many of them were on Medicare and Medicaid? Some I am sure. I know of at least one, MYSELF.

If so many of you are so slammed with fraud by Medicaid patients, why do you not do your civic duty, your civic responsibility and report them. I have reported people for suspect fraud. It is difficult but it is something that can be done. And even if it didn't result in a charge, it got them looked at more closely.

Grannynurse:balloons:

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