Mostly middle class Rego Park is the highest billing ZIP code in the state for Medicaid, according to a recently published news report.
But the Office of the Medicaid Inspector General told the Chronicle this week that it’s for good reason: one of the largest managed care companies in the Empire State is headquartered in 11374.
According to NBC New York, Rego Park accounts for 7 percent of the state’s $20 billion Medicaid budget — roughly $1.5 billion in 2010.
The numbers raise eyebrows because, as NBC pointed out, the median annual salary of Rego Park is nearly three times the maximum a single person can earn and still be eligible for Medicaid.
However, a spokeswoman for the OMIG said on Tuesday, the figures are skewed by the presence of Fidelis Care on Queens Boulevard.
“The top place that gets Medicaid [in Rego Park] is a managed care company,” said Public Information Officer Wanda Fischer. “The main reason is that there is a bona fide managed care company getting money and [reimbursing] providers.”
Fischer quickly noted that “[Fidelis] is a very fine, upstanding managed care company that follows the rules and does what they’re supposed to do,” adding that not all of its beneficiaries are Rego Park residents.
“It really takes a lot of interpretation,” Fischer said. “Managed care is a real benefit to a lot of Medicaid people.”
According to the OMIG, the top six Medicaid user categories in 11374 are Fidelis, pharmacy, free-standing clinic, transportation provider, physician services and dentist.
But, as the NBC report noted, fraud remains a problem in the state Medicaid system, and Rego Park is not immune. ASA Pharmacy on 63rd Road recently was involved in a federal investigation for its role in a multi-million-dollar fraud scheme. The results of the probe were not available.
Fischer said that while the OMIG does not have prosecutorial power, it has two divisions which investigate suspicious Medicaid activity, and a sophisticated data-mining system to alert the office to red flags.
“If we find something we believe to be fraudulent, we work with law enforcement,” including the state attorney general and local police departments, she said.
Red-flag activities, Fischer explained, can run the gamut from dentists billing for work that was never done, or what’s known as “doctor shopping,” a practice in which some Medicaid recipients visit several doctors in the same period of time for the same medication and get the prescriptions filled at different pharmacies.
“Drugs are a big problem, because a lot of people are addicted,” she said. “And drug addicts are very creative.”
Fischer said the OMIG regularly performs credential verification review, maintains a Restricted Recipient Program, and a list of providers — now more than 17,000 — who have been excluded from participating in Medicaid.
“This means they would not be able to work in a place funded by Medicaid,” she said.
Fischer added that the office emphasizes compliance to providers to help prevent any unintentional clerical errors that can lead to incorrect billing.
“[But] even if it’s an innocent mistake, it’s still a mistake,” she said.
For more information, or to report suspicious activity, visit omig.ny.gov or call (877) 87-FRAUD (37283).