HMO is fined $55,000 for tricking poor Medicaid patients enrolled improperly in 3 cases, state says

Optimum Choice appealing

One woman enrolled after session including sex with marketer

March 25, 1996|By Diana K. Sugg | Diana K. Sugg,SUN STAFF

State health officials have fined a health maintenance organization $55,000, charging that the health plan's employees tricked and manipulated poor people to enroll in the plan.

Marketing employees of Optimum Choice Inc. were involved in three instances of misrepresentation or fraud in the past several months, the state officials said.

The three include a mentally ill woman who was taken to a marketer's house, where he had sex with her and got her to enroll in the plan, according to documents obtained last week from the state Department of Health and Mental Hygiene under the Freedom of Information Act.

Of the six HMOs that serve Maryland's Medicaid population, Optimum Choice is the first to be fined for marketing abuses.

State officials inserted the fines in the HMOs' contracts last year as a way to curb such tactics as forgery and bribery that some of the health plans' employees were using in the aggressive competition to recruit Medicaid patients.

Attorneys for Optimum Choice, which has served Medicaid recipients in Maryland for a few years, said they are appealing the fines through a state administrative hearing process.

They contend health officials have no authority to fine them, and that the state is overlooking the company's "rigorous training program" for its marketers.

Optimum Choice also disputes the state's version of the incidents that resulted in fines. But even if fraud was committed or facts were misrepresented to potential patients, the HMO's lawyers said, the marketers were acting outside their relationship with the HMO.

In the instance involving the mentally ill woman, Optimum Choice employee Bruce Hocker approached her on a Prince George's County street in October. He drove the 21-year-old Prince George's woman to his Beltsville home, gave her lunch and an enrollment presentation, and obtained her signature on an enrollment form. At some point, he had sex with her, state documents said. The documents do not provide further details.

The woman, who is diagnosed with language and bipolar disorders and has a low IQ, is easily distracted, misled and persuaded by authority figures, according to one of her medical providers.

An acquaintance of the woman took her to Prince George's police, and officers investigated the incident, the state documents said. But the woman told them the sex was consensual, and the state's attorney declined to file criminal charges, police said.

Optimum Choice told the state it terminated Mr. Hocker for other reasons before the state's investigation. Mr. Hocker could not be reached for comment.

The woman's situation reflects the vulnerability of Medicaid recipients. They are among the poorest of the poor and the sickest of the sick. For years, community doctors and clinics were the only providers to care for them. But as states struggle to pay escalating Medicaid bills, they have begun to move these patients into HMOs to hold down costs to taxpayers. The shift to HMOs also is designed to improve patients' access to medical care by assigning them to a specific doctor.

Now, HMO officials said states have made it tough for them to find these potential customers. Abuses have occurred from New York to California. Some states have frozen enrollment. Others have hired independent firms or done the marketing themselves.

In Maryland, the state is paying HMOs about $288 million to care for roughly a quarter of the 467,000 residents on Medicaid. A proposal to shift another 250,000 of these patients into HMOs is making its way through the General Assembly. Under that proposal, Maryland health officials have said, they would not allow HMOs to do the marketing themselves. Instead, they would be recruited by an independent firm or the state.

Last year, an investigation by the attorney general's office uncovered marketers paying Baltimore social workers to turn over the confidential names of Medicaid recipients. More than two-dozen people were found guilty of crimes ranging from bribery and forgery to Medicaid fraud.

Lawrence P. Triplett, director of the state's Medical Care Finance and Compliance Administration, said his office received two complaints from Medicaid recipients about marketing in January and four last month. That compares with about 14 in each of the preceding four months. Often, the complaint is that marketers misled the patient.

That is what state officials said was the case in Optimum Choice's second contract violation, which occurred during a marketer's presentation to a Medicaid recipient at her Baltimore home in August.

Marketer Leonard Washington told her the popular Maryland Access to Care -- part of the Medicaid program in which patients have a designated physician who acts as a gatekeeper for their care -- was changing its name to Optimum Choice, state documents said. The marketer's supervisor later used a newspaper article to try to prove that assertion.

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