Medicaid Abuse

So you say that the people on the Caid need it and deserve it, here is a story for you. Seattle PI At a time when lawmakers struggled to find money for health care for the state's most vulnerable people, Washington taxpayers footed the bill for a sex-change operation, penile implants, breast augmentation and ear piercings. In his most recent review of state Medicaid expenses, Auditor Brian Sonntag found thousands of questionable expenditures in the 2004 fiscal year. One in particular jumped off the page. Medicaid paid $9,549.92 to surgically transform a woman into a man. You can read it all in the extended section. "You pick up the paper or watch the evening news and you see senior citizens who can't get medications of diabetes and things," Sonntag said. "And here you see tax dollars being used for things like this, it makes you ask, 'Why?' " Previously unreleased details from last year's audit question the necessity of several other procedures the state subsidized. The documents show the state spent at least $3,500 to insert and repair penile implants, $40,000 on plastic and cosmetic surgery and more than $100,000 on unauthorized breast implants and augmentation. Two people had their ears pierced at a total cost of $210, according to the report. Officials at the Department of Social and Health Services have disputed many of the findings in the report but not that any of the procedures were provided and paid for. Each year, the state and federal government spends more than $3 billion through Medicaid to pay for health care of the poor and disabled. advertising In 2004, more than 850,000 Washington citizens, nearly two-thirds of them children, depended on the Medicaid program for their health care. DSHS administers Medicaid and several associated medical-assistance programs. The program relies on a split of state and federal money. Sonntag said the evidence in the report's small sampling of the entire Medicaid budget indicates that the state could be spending tens of millions of dollars on questionable procedures. State Medicaid Director Doug Porter said the department takes issue with Sonntag's conclusion that the procedures were unallowable expenses. "The debate would be whether or not they were medically necessary," Porter said. "And medical necessity is a term that is, as we speak, is undergoing revision. ... There are many things that we have traditionally paid for that were deemed medically necessary that we are calling into question on a more frequent basis." But a sex-change operation still could be covered by Medicaid. "Gender dysphoria is the diagnosis, the treatment for which is gender reassignment," Porter said. "Some physician has determined that it's a man who really should be a woman and they are suffering psychological effects of this condition, and the only correction to restore them to a higher function is a sexual reassignment." Porter said the treatment, which was identified by the agency as a specifically covered benefit years ago, is a sensational issue that has very little effect on the agency. "We're talking about a handful of people over a long period of time," Porter said. In 2003 the department changed its approval policy for sex-change operations, because the medical community determined medication and psychotherapy were as effective as surgery to treat the condition. Now the agency insists that patients try less costly and less severe interventions before it would approve a sex-change operation. "We're not saying we don't cover this anymore," Porter said. "We're saying the conditions under which we would authorize these much more expensive surgical procedures are much tighter." Porter said the incidents raised by Sonntag's audit were isolated and should not be extrapolated out. When the department reviewed a sampling of the cases flagged in the audit, they found the procedures had been authorized and were therefore allowable, he said. And given Medicaid's multibillion-dollar budget, hundreds, even thousands of dollars that might go unaccounted for are immaterial, Porter said. "Immaterial to who?" Sonntag said. "To taxpayers and in my work, any amount is material." There are several reasons other than vanity that the 39 women identified in the audit may have had breast reductions, Porter said. Sonntag stood by the veracity of his report. "Certainly there can be medical reasons for breast augmentation, a cancer surgery for instance," Sonntag said. "So we were very careful to look at those, and then look at them again, to make sure that these were not in that category." "These kinds of procedures would be cosmetic and we identified those specifically," Sonntag said. "We don't want to be calling attention to procedures that certainly would be allowable, so these are outside of that." Sonntag said he is certain that the breast augmentations identified in the audit were cosmetic. "We don't want to be falsely accusing the agency or individuals or bringing up information that would be alarming to someone needlessly," he said. The report generated considerable bad blood between the auditor's office and DSHS. State auditors accused the department of stonewalling and the department accused the auditors of being unfairly adversarial. That's changed under the agency's new director, Robin Arnold-Williams, Sonntag said. "The attitude and communication, the agency-to-agency relationship seems to be much better," he said. "There will be issues that we address this year that we probably addressed last year. Not everything is going to get fixed instantly." But Sonntag said bad blood had nothing to do with the findings. "We didn't go looking for issues, and certainly we don't make things up," Sonntag said. "Our information is objective, it's accurate." Sonntag said he could only speculate about how someone could justify some of these procedures as medical necessities. "But the watchdog part has to come at the money end, at the approval," he said. "If I go into the doctor's, they are going to call my insurance company and see if this thing they want to do, this test is covered, or this medication is covered. If they say no, then, it's no. That doesn't seem to happen ... on these and these are big deals." The 2005 Medicaid report is due out as early as March. "We don't have the report out yet, but it would be safe to guess that there will be issues in this year's audit report that were brought up last year," Sonntag said.