LOUISIANA DEPARTMENT OF HEALTH MEDICAID RECIPIENT – NAJI ABDELSALAM

INVESTIGATIVE AUDIT ISSUED APRIL 17, 2019

LOUISIANA LEGISLATIVE AUDITOR 1600 NORTH THIRD STREET

POST OFFICE BOX 94397 BATON ROUGE, LOUISIANA 70804-9397

LEGISLATIVE AUDITOR DARYL G. PURPERA, CPA, CFE

DIRECTOR OF INVESTIGATIVE AUDIT ROGER W. HARRIS, J.D., CCEP, CFI

Under the provisions of state law, this report is a public document. A copy of this report has been submitted to the Governor, to the Attorney General, and to other public officials as required by state law. A copy of this report is available for public inspection at the Baton Rouge office of the Louisiana Legislative Auditor and at the office of the parish clerk of court. This document is produced by the Louisiana Legislative Auditor, State of Louisiana, Post Office Box 94397, Baton Rouge, Louisiana 70804-9397 in accordance with Louisiana Revised Statute 24:513. Two copies of this public document were produced at an approximate cost of $0.90. This material was produced in accordance with the standards for state agencies established pursuant to R.S. 43:31. This report is available on the Legislative Auditor’s website at www.lla.la.gov. When contacting the office, you may refer to Agency ID No. 3347 or Report ID No. 82180003 for additional information. In compliance with the Americans With Disabilities Act, if you need special assistance relative to this document, or any documents of the Legislative Auditor, please contact Elizabeth Coxe, Chief Administrative Officer, at 225-339-3800.

LOUISIANA LEGISLATIVE AUDITOR

DARYL G. PURPERA, CPA, CFE

1600 NORTH THIRD STREET • POST OFFICE BOX 94397 • BATON ROUGE, LOUISIANA 70804-9397

WWW.LLA.LA.GOV • PHONE: 225-339-3800 • FAX: 225-339-3870

April 17, 2019 DR. REBEKAH E. GEE, SECRETARY LOUISIANA DEPARTMENT OF HEALTH Baton Rouge, Louisiana

We are providing this report for your information and use. This investigative audit was performed in accordance with Louisiana Revised Statutes 24:513, et seq. to determine the validity of complaints we received.

We found that Naji and Shifa Abdelsalam filed false information with, and failed to disclose all

of their income to, the Louisiana Department of Health (LDH) when they applied for Medicaid benefits for themselves and their five children. By failing to do so, the Abdelsalams received $73,563 in benefits between June 2016 and September 2018 for which they may not have been eligible.

We were assisted in our audit by the Louisiana Department of Justice Bureau of Investigation,

which arrested Mr. Abdelsalam on March 19, 2019. He was charged with one count of theft over $25,000, one count of government benefits fraud, and one count of filing or maintaining false public records.

In addition, Mr. Abdelsalam was charged with 10 counts of Medicaid fraud and one count of

criminal conspiracy for actions allegedly committed as a Medicaid service provider. The procedures we performed primarily consisted of making inquiries and examining selected

financial records and other documents and do not constitute an examination or review in accordance with generally accepted auditing or attestation standards. Consequently, we provide no opinion, attestation, or other form of assurance with respect to the information upon which our work was based.

The accompanying report presents our findings and recommendations, as well as management’s

response. This is a public report. Copies of this report have been delivered to the District Attorney for the 9th Judicial District of Louisiana, the District Attorney for the 19th Judicial District of Louisiana, and others as required by law.

Respectfully submitted, Daryl G. Purpera, CPA, CFE Legislative Auditor

DGP/aa LDH ABDELSALAM

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TABLE OF CONTENTS

Page Executive Summary .........................................................................................................................2

Background and Methodology .........................................................................................................3

Findings and Recommendations:

Recipients Provided False Information to Obtain Medicaid Benefits ...........................................5

Legal Provisions .............................................................................................................................11

Management’s Response ............................................................................................... Appendix A

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EXECUTIVE SUMMARY

Recipients Provided False Information to Obtain Medicaid Benefits

From June 2016 to September 2018, Naji Abdelsalam and his spouse, Shifa Abdelsalam, provided false information to the Louisiana Department of Health (LDH) to obtain $73,563 in Louisiana Medicaid (Medicaid) benefits for themselves and their five children. During this period, Naji and Shifa Abdelsalam failed to disclose to LDH all of their income. Had they provided accurate information to LDH, the Abdelsalams and their dependent children may have been ineligible to receive Medicaid benefits. Further, if Naji and Shifa Abdelsalam provided false information to LDH and failed to disclose all income, they may have violated state law.

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BACKGROUND AND METHODOLOGY

The Louisiana Department of Health (LDH) is an executive branch department that reports to the governor. LDH’s mission is to protect and promote health and to ensure access to medical, preventative, and rehabilitative services for all citizens of the state of Louisiana. LDH is responsible for developing and providing health and medical services for the prevention of disease for the citizens of Louisiana. LDH provides health and medical services for uninsured and medically indigent persons and also coordinates the delivery of services provided by the Louisiana State University Health Sciences Center with services provided by the Louisiana Department of Health, local health departments, and federally-qualified health centers, including but not limited to, the following:

Services for:

Persons with mental illness;

Persons with intellectual disabilities;

Persons with developmental disabilities; and

Persons with addictive disorders.

Public health services.

Services provided under the medical assistance program (Medicaid).

LDH administers the Medicaid program to provide health and medical services for uninsured and medically-indigent citizens. In 2012, LDH began transitioning from a fee-for-service (FFS) model, where LDH paid all claims submitted by Medicaid providers for each service performed, to Healthy Louisiana,A a full-risk prepaid managed care model. Under LDH’s current full-risk prepaid managed care model, LDH pays a fixed monthly fee to a Managed Care Organization (MCO) for the administration of health benefits and payment of all claims for each member. LDH contracted with five MCOs to operate the Healthy Louisiana Medicaid program through December 31, 2019. However, LDH is responsible for determining Medicaid recipient eligibility and enrolling applicants into Medicaid programs. In October 2018, Louisiana Legislative Auditor (LLA) staff performed eligibility reviews on a sample of Medicaid recipients. During the review process, LLA staff identified a Medicaid recipient in Rapides Parish, Naji Abdelsalam, who had multiple businesses for which no income was reported on the recipient’s Medicaid application. Mr. Abdelsalam also owns and operates a non-emergency medical transportation company that provides services to Medicaid recipients.

A Healthy Louisiana was previously called Bayou Health. A managed care model is an arrangement for health care in which an organization (e.g., an MCO), acts as a gatekeeper or intermediary between the person seeking care and the physician. FFS still covers some Medicaid recipients who are not eligible for managed care.

Louisiana Department of Health Background and Methodology

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LLA initiated this investigative audit to determine if Mr. Abdelsalam provided LDH with accurate information. The procedures performed during this audit included:

(1) interviewing LDH employees;

(2) interviewing other persons, as appropriate;

(3) examining selected LDH documents and records;

(4) gathering and examining external parties’ documents and records; and

(5) reviewing applicable state laws and regulations.

During our audit, we received assistance from the Louisiana Department of Justice’s Bureau of Investigation. Their participation was instrumental to the completion of this audit. On March 19, 2019, Mr. Abdelsalam was arrested on one count of theft over $25,000, one count of government benefits fraud, and one count of filing or maintaining false public records. In addition, Mr. Abdelsalam was charged with 10 counts of Medicaid fraud and one count of criminal conspiracy for actions allegedly committed as a Medicaid service provider.

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FINDINGS AND RECOMMENDATIONS

Recipients Provided False Information to Obtain Medicaid Benefits

From June 2016 to September 2018, Naji Abdelsalam and his spouse, Shifa Abdelsalam, provided false information to the Louisiana Department of Health (LDH) to obtain $73,563 in Louisiana Medicaid (Medicaid) benefits for themselves and their five children. During this period, Naji and Shifa Abdelsalam failed to disclose to LDH all of their income. Had they provided accurate information to LDH, the Abdelsalams and their dependent children may have been ineligible to receive Medicaid benefits. Further, if Naji and Shifa Abdelsalam provided false information to LDH and failed to disclose all income, they may have violated state law.1,2,3,4

Medicaid provides health coverage to more than 1.6 million Louisianans, including eligible low-income adults, children, pregnant women, elderly adults, and people with disabilities. The Medicaid program is administered by LDH, according to federal requirements, and is funded jointly by Louisiana and the federal government. Applicants can apply for benefits through the Louisiana Medicaid Online Application Center or by filling out a paper application form. When submitting an application, the applicant agrees that the information provided is true and correct, and that providing false information or intentionally withholding information may result in prosecution and/or repayment of bills that were paid improperly. Medicaid records show that Naji Abdelsalam, his spouse (Shifa Abdelsalam), and their five dependent children received $73,563 in Medicaid benefits from April 2016 to September 2018. LDH records show that Naji Abdelsalam disclosed only $2,800 per month in earnings from a gas station on the initial Medicaid application filed on June 23, 2016. (Although the Abdelsalams did not file until June 2016, some benefits were paid retroactively to April 2016.) However, we found that Naji Abdelsalam owned and/or operated several businesses at the time, including Five Star Medical, Inc. (Five Star Medical), a non-emergency medical transportation company that provided services to Medicaid recipients, for which Five Star Medical received $769,377 from September 8, 2015 through June 21, 2016, two days before he filed his application for Medicaid benefits.

One document that was provided to LDH was a letter from a woman claiming to be Five Star Medical’s Director of Personnel; she said Naji Abdelsalam worked at Five Star Medical as a dispatcher and was paid $600 per week. The Abdelsalams provided LDH with copies of what purported to be paychecks from Five Star Medical to Naji Abdelsalam supporting the pay set forth in the letter. However, according to the Louisiana Secretary of State (SoS) website, Naji Abdelsalam is the sole officer and registered agent for Five Star Medical. In addition, documents Naji Abdelsalam filed with LDH to enroll Five Star Medical as a Medicaid provider list him as the only owner and director of Five Star Medical. Moreover, we found that none of the payroll checks the Abdelsalams provided to LDH were negotiated and, therefore, could not have been his paychecks.

Louisiana Department of Health Findings and Recommendations

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Businesses Owned and/or Operated by Naji Abdelsalam

Five Star Medical is a Louisiana corporation that registered with the SoS on January 26, 2015. According to SoS records, Naji Abdelsalam is the corporation’s only officer and registered agent. Naji Abdelsalam submitted an application to LDH for Five Star Medical to become a Medicaid provider on January 28, 2015. According to that application, Naji Abdelsalam was the sole owner of Five Star Medical. From September 2015 to June 2018, Five Star Medical was paid $4,148,887 for providing non-emergency medical transportation services to Medicaid recipients.

In addition to owning Five Star Medical, Naji Abdelsalam appears to own and/or operate

(or have owned and/or operated) multiple service stations and an automotive repair/tire shop. Records obtained from the Rapides Parish Clerk of Court’s (Clerk of Court) office show that Two Guys Enterprise, Inc. (Two Guys Enterprise),B a company registered by Naji Abdelsalam, filed and recorded a Registration of Assumed Business Name on June 12, 2014, which indicated that Two Guys Enterprise was operating a business under the assumed name of Magic Mart. Naji Abdelsalam also filed and recorded a Registration of Assumed Business Name on August 8, 2014, and January 15, 2015, indicating that he was operating businesses under the assumed names of Quick Stop and Broadway Tires and Service Center, respectively. Recipients Failed to Disclose Income From All Businesses LDH records show that Naji Abdelsalam completed an online Medicaid application on June 23, 2016, requesting benefits for himself, his spouse (Shifa Abdelsalam), and four dependent children.C Although Naji Abdelsalam reported that he earned $2,800 per month in income from a service station, he did not disclose income from any other source, including Five Star Medical. We obtained bank records for Five Star Medical and all other accounts at the same bank for which Naji Abdelsalam had signature authority from January 2016 to October 2018. In addition to Five Star Medical, these accounts included; Majic Mart Inc. DBA Broadway Tires and Service Center; Naji Abdelsalam DBA Quick Stop; Khaled N. Abdelsalam DBA Five Star Imports; Two Guys Enterprise Inc., DBA Magic Mart; and one personal bank account in the name of Khaled Abdelsalam and Naji Abdelsalam.

According to Medicaid records, Five Star Medical was paid $769,377 for Medicaid services allegedly rendered from September 8, 2015 to June 21, 2016, two days before he filed his application for Medicaid benefits. Although Five Star Medical did not issue any checks directly to Naji Abdelsalam, Five Star Medical transferred $218,214 to his other business and personal bank accounts from January 13, 2016 to June 23, 2016. For example, Five Star Medical transferred funds to the Two Guys Enterprise bank account monthly. Those funds were used to pay the mortgage for Naji Abdelsalam’s personal residence, as well as credit accounts in his name.

B Two Guys Enterprise, Inc. is a Louisiana corporation that registered on February 20, 2002. The corporation’s domicile address is the same as Naji Abdelsalam’s home address, and he is listed as the registered agent, president, and director. C According to LDH, the 2016 monthly income limit for Medicaid benefits was $4,224 for the two adults and $6,643 for the four children.

Louisiana Department of Health Findings and Recommendations

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In addition, a personal bank account in the name of Khaled Abdelsalam and Naji Abdelsalam appears to have been used to pay for personal expenses, including credit accounts and life insurance premiums for Naji Abdelsalam, and a credit account for a family member. This bank account had a balance of $29,670 on the date that Naji Abdelsalam applied for Medicaid benefits. Recipients Provided False Information to LDH

After receipt of Naji Abdelsalam’s initial Medicaid application in June 2016, LDH sent him requests for information (RFIs) on July 6, 2016, July 20, 2016, and August 9, 2016, for proof of earnings. In response to the July 20th RFI, LDH received a letter from Five Star Medical’s Director of Personnel stating that Naji Abdelsalam had been an employee (dispatcher) since February 2016 with gross pay of $600 per week. Further, LDH records indicate that Shifa Abdelsalam faxed LDH copies of two checks on August 17, 2016. These checks appear to have been issued to Naji Abdelsalam from Quick Stop in the amounts of $155 and $136 and indicate that he worked a total of 45 hours at a rate of $8.00 per hour from July 18, 2016 to August 13, 2016. Based on the information provided, all family members were deemed eligible for Medicaid benefits through June 30, 2017.

We reviewed Five Star Medical bank records and found no checks, withdrawals,

electronic debits, or other evidence to support the claim that Five Star Medical paid Naji Abdelsalam $600 weekly. As mentioned above, there were no checks issued directly to Naji Abdelsalam; however, Five Star Medical transferred $218,214 to other business and personal bank accounts on which he was a signatory. In addition, Quick Stop bank records show that the checks provided to LDH (see above) were not negotiated.

In order to renew their Medicaid coverage for the 12-month period beginning July 1,

2017, the Abdelsalams completed another application on May 1, 2017, requesting benefits for themselves and their fiveD dependent children.E The application stated that Naji Abdelsalam was employed by Five Star Medical at the rate of $700 every two weeks, or $16,800 annually. On May 18, 2017, LDH sent Naji Abdelsalam a closure letter because he failed to respond to an RFI for proof of earnings from businesses that he owned. In response to the closure letter, LDH was provided with the following documentation dated May 24, 2017:

Letter from Five Star Medical stating that Naji Abdelsalam is an employee (since

January 2016) being paid $484.41 per week. Also attached was a 2016 IRS Form W-2 for Naji Abdelsalam showing wages of $25,000.

Letter from Majic Mart Inc.,F indicating that the corporation was in the process of being dissolved and there was no income or sales.

D The Abdelsalams had four children at the time of the first application; the fifth child was born approximately eight months later. E According to LDH, the 2017 monthly income limit for Medicaid benefits was $4,272 for the two adults and $6,717 for the five children. F Majic Mart Inc. was a Louisiana corporation that registered on August 8, 2008. Naji Abdelsalam was the only director, and the corporation was administratively terminated on November 7, 2015.

Louisiana Department of Health Findings and Recommendations

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Letter from Three Guys Enterprise, Inc.G stating that the corporation was established in March 2017 but had no sales or income.

Each of the letters mentioned above appear to have been signed by Naji Abdelsalam using the title of “Director” for each company. Based on the information provided, all family members continued to qualify for Medicaid benefits through November 2017. Medicaid records for May 2016 to April 2017 (12-month period before the Medicaid application of May 1, 2017) show that Five Star Medical received $1,221,544 for Medicaid services. There were no checks, withdrawals, or electronic debits issued directly to Naji Abdelsalam to support the 2016 IRS Form W-2 for Naji Abdelsalam showing wages of $25,000; however, during this period, Five Star Medical appears to have converted $218,597 to cash in the form of debit memos. In addition, Five Star Medical transferred $428,256 to Naji Abdelsalam’s other business and personal bank accounts, including Two Guys Enterprise, which continued to pay the mortgage for his personal residence as well as credit accounts in his name. Finally, the personal bank account in the name of Naji Abdelsalam and Khaled Abdelsalam had a balance of $89,071 on May 1, 2017. Electronic Medicaid claim notes show that a case worker contacted the Abdelsalams on October 24, 2017, to verify household income prior to coverage ending in November 2017. According to the case worker’s notes, the Abdelsalams indicated that Naji Abdelsalam was working for Five Star Medical and “would fax over income” (information). On the same day, LDH received faxed copies of two checks payable to Naji Abdelsalam from Five Star Medical. The first check, in the amount of $784.88, was dated October 6, 2017, for the two weeks ending October 6, 2017. The second check, in the amount of $744.06, was dated October 20, 2017, for the two weeks ending October 20, 2017. These checks gave the appearance that Naji Abdelsalam was being paid $484.41 per week (gross wages) as purported in the letter from Five Star Medical on May 24, 2017. Based on this information, all family members continued to qualify for Medicaid benefits. We reviewed Five Star Medical bank records and found that neither check had been negotiated. Funds Available to Naji Abdelsalam While Receiving Medicaid Benefits We reviewed a total of six business and personal bank accounts for which Naji Abdelsalam had signature authority from January 1, 2016 to October 31, 2018. These bank accounts included the following:

Five Star Medical, Inc.

Two Guys Enterprise, Inc. DBA Magic Mart

Majic Mart Inc. DBA Broadway Tires and Service Center

G Three Guys Enterprise, Inc. is a Louisiana corporation that registered on January 4, 2017. The corporation’s domicile address is the same as Naji Abdelsalam’s home address, and he is listed as the registered agent and president. We did not have any records to determine if Three Guys Enterprise, Inc. had any sales or income since its inception.

Louisiana Department of Health Findings and Recommendations

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Naji K. Abdelsalam DBA Quick Stop

Khaled N. Abdelsalam DBA Five Star ImportsH

Khaled N. Abdelsalam, Naji K. Abdelsalam (personal account).

During this period, Five Star Medical received $4,084,584 for providing non-emergency medical transportation services to Medicaid recipients. According to bank records, Five Star Medical converted $655,364 to cash in the form of debit memos, transferred funds totaling at least $847,074 to other accounts for which Naji Abdelsalam was a signatory, and paid credit accounts in his name, the name of the business, and name of one of his family members.

Because no checks were issued to Naji Abdelsalam from any of these accounts that were negotiated, we calculated the combined, average ending (monthly) balance for these accounts to determine the amount of funds available to Naji Abdelsalam on a monthly basis. From January 1, 2016 to October 31, 2018, the combined, average ending balance for these accounts was $188,428. Conclusion

From June 2016 to September 2018, Naji and Shifa Abdelsalam provided false information to LDH to obtain Medicaid benefits totaling $73,563 for themselves and their five children. During this period, Naji and Shifa Abdelsalam failed to disclose to LDH all income. Had they provided accurate information to LDH, the Abdelsalams and their dependent children may have been ineligible to receive Medicaid benefits. Further, if Naji and Shifa Abdelsalam provided false information to LDH and failed to disclose all income, they may have violated state law.1,2,3,4

Recommendations

We recommend that LDH management seek legal counsel to determine the appropriate action to be taken, including the recovery of payments for improper Medicaid benefits. In addition, LDH management should:

(1) Strengthen its processes for eligibility determinations to include verification of all critical eligibility factors rather than relying on self-attestation from the recipient;

(2) Ensure that its caseworkers re-determine eligibility when they receive information that may affect eligibility of the recipient;

(3) Consider obtaining federal income tax data to assist in making eligibility determinations;

H Although Five Star Imports is inactive with the SoS, Khaled Abdelsalam filed and recorded a Registration of Assumed Business Name for Five Star Imports on April 14, 2014.

Louisiana Department of Health Findings and Recommendations

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(4) Ensure that caseworkers document information used to make eligibility decisions; and

(5) Compare Medicaid applicants to LDH’s Medicaid providers’ database to identify applicants who may not be eligible to receive Medicaid benefits.

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LEGAL PROVISIONS

1 Louisiana Revised Statute (La. R.S.) 14:67(A) provides that, “Theft is the misappropriation or taking of anything of value which belongs to another, either without the consent of the other to the misappropriation or taking, or by means of fraudulent conduct, practices, or representations. An intent to deprive the other permanently of whatever may be the subject of the misappropriation or taking is essential.” 2 La. R.S. 14:133(A) provides that, “Filing false public records is the filing or depositing for record in any public office or with any public official, or the maintaining as required by law, regulation, or rule, with knowledge of its falsity, of any of the following: (1) Any forged document. (2) Any wrongfully altered document. (3) Any document containing a false statement or false representation of a material fact.” 3 La. R.S. 14:125(A) provides that, “False swearing is the intentional making of a written or oral statement, known to be false, under sanction of an oath or an equivalent affirmation, where such oath or affirmation is required by law; provided that this article shall not apply where such false statement is made in, or for use in, a judicial proceeding or any proceeding before a board or official, wherein such board or official is authorized to take testimony.” 4 La. R.S. 46:114 provides in part that, “(A) No person shall obtain or attempt to obtain assistance from the Department of Children and Family Services or the Louisiana Department of Health by means of any false statement, misrepresentation, or other fraudulent device. If during the life, or upon the death, of any person who is receiving or has received assistance it is found that the recipient is receiving or has received assistance through misrepresentation, nondisclosure of material facts, or other fraudulent device, the amount of assistance, without interest, shall be recoverable from him or his estate as a debt due the state by court action.” (B) If at any time during the continuance of public assistance to any person, the recipient thereof, or the husband or wife of the recipient with whom he or she is living, is possessed or becomes possessed of any property or income in excess of the amount declared at the time of application or reinvestigation of his case and in such amount as would affect his needs or right to receive assistance, it shall be the duty of the recipient, or the husband or wife of the recipient, to notify the Department of Children and Family Services or the Louisiana Department of Health of possession of such property or income, and the department shall, after investigation, either cancel the assistance or alter the amount thereof in accordance with the circumstances, provided, that such investigation shows that such property or income does affect the need of the recipient or his right to receive assistance. If during the life, or upon the death, of any person who is receiving or has received assistance it is found that the recipient or his spouse was possessed of any property or income in excess of the amount reported that would affect his need or right to receive assistance, any assistance paid when the recipient or his spouse was in possession of such undeclared property or income shall be recoverable, without interest, from him or his estate as a debt due the state by court action. The possession of undeclared property by a recipient or his spouse with whom he is living shall be prima facie evidence of its ownership during the time assistance was granted, and the burden to prove otherwise shall be upon the recipient or his legal representative. (C)(1) If the personal circumstances of the recipient change at any time during the continuance of assistance, he shall immediately notify the Department of Children and Family Services or the Louisiana Department of Health of the change. Personal circumstances shall include: (a) The members of the household. (b) The place of residence of the recipient. (c) The establishment of a legal or nonlegal union by the recipient. (d) The failure of a child between the ages of sixteen and eighteen years, who is receiving aid to dependent children, to attend school regularly.”

APPENDIX A

Management’s Response

John Bel Edwards GOVERNOR

VIA E-MAIL ONLY

April9, 2019

6tate of l.ouistana Louisiana Department of Health

Office of Management and Finance

Daryl G. Purpera, CPA, CFE Legislative Auditor P. 0. Box 94397 Baton Rouge, Louisiana 70804-9397

Re: Investigative Audit Repott- Abdelsalam

Dear Mr. Purpera:

Rebekah E. Gee MD, MPH SEC.RETARY

Thank you for the opportunity to respond to the findings of your Medicaid Audit Unit repott on the Medicaid eligibility ofNaj i and Shifa Abdelsalam. The Bureau of Health Services Financing, which is responsible for the administration of the Medicaid program in Louisiana, is committed to ensuring the integrity of the Medicaid eligibility determination process through appropriate management controls.

We reviewed the findings and provide the following responses to the recommendations documented in the repott.

Overall Recommendation: We recommend that LDH management seek legal counsel to determine the appropriate action to be taken, including the recovery of payments for improper Medicaid benefits.

LDH Response: LDH will seek legal counsel to determine the appropriate action to be taken, including the recovery of payments for improper Medicaid benefits, in accordance with federal and state authorities.

Recommendation 1: LDH should strengthen its processes for eligibility determinations to include verifications of all critical eligibi lity factors rather than relying on self-attestation from the recipient.

LDH Response: LDH agrees with strengthening its processes for eligibility determinations to verifY eligibility where self-attestation from the recipient is a factor. Medicaid's new eligibility and enrollment system strengthened the eligibility detennination process by automating eligibility factor verification using 20 different external, electronic data sources. Beginning in May 2019, federal tax inf01mation (FTI) will be an additional source available for eligibility factor verification, which will repott total household income. LDH plans to expand the use of FTI in the future to include household composition verification.

Bienville Building • 628 N. Fourth St. • P.O. Box 91030 • Baton Rouge, Louisiana 70821-9030 Phone: (888) 342-6207 • Fax: (225) 342-9508 • www.dhh.la.gov

An Equal Opportunity Employer

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Mr. Daryl G. Purpera April 9, 2019 Page 2

Recommendation 2: LDH should ensure that its caseworkers re-determine eligibility when they receive information that may affect eligibility of the recipient.

LDH Response: LDH agrees with this recommendation. It will continue to reinforce caseworker training on agency policy requiring eligibility redetetmination when information is received that may affect eligibility of a recipient, consistent with federal law. Additionally, the new eligibility and enrollment system automatically redetermines Medicaid eligibility when new information is received, and it automatically stores information on which determinations are based.

Recommendation 3: LDH should consider obtaining federal income tax data to assist in making eligibility determinations.

LDH Response: LDH agrees with this recommendation. Beginning in May 2019, federal tax information, to include total household income, will be an additional electronic data source available to assist in making eligibility determinations. LDH plans to expand the use of FTI in the future to include household composition verification.

Recommendation 4: LDH should ensure that caseworkers document information used to make eligibility decisions.

LDH Response: LDH agrees with this recommendation. It will continue to reinforce caseworker training on agency policy requiring documentation of information used to make eligibility decisions and conduct supervisory reviews of caseworker actions to ensure compliance. Additionally, the new eligibility system automatically stores information on which eligibility decisions are based.

Recommendation 5: LDH should compare Medicaid applicants to LDH's Medicaid providers' database to identify applicants who may not be eligible to receive Medicaid benefits.

LDH Response: LDH agrees with this recommendation. It will use Medicaid provider ownership information in its program integrity data mining activities.

You may contact Michael Boutte, Medicaid Deputy Director, at (225) 342-0327 or vial e-mail at Michae i. Boulle@la.gov with any questions about this matter.

Sincerely,

Cindy Rives Undersecretary

CR!js

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