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Jacquelyn Sommer

New Mexico Behavioral Health Providers Cleared of Fraud Allegations

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Last week in New Mexico, the state Attorney General, Hector Balderas, cleared the last two of 15 behavioral health providers of allegations of Medicaid fraud.  The 13 other providers were cleared earlier this year. The move came after several years of investigation, in which Medicaid payments to the affected agencies were halted and many were forced to close their doors.


In a statement to the press, Balderas summarized the dichotomy of the situation, “The department must find a way to fight fraud that does not put services to the most vulnerable at risk or result in hundreds of New Mexicans losing their jobs.”


Since the payment stoppage, New Mexico experienced severe disruptions in service delivery and a sudden lack of infrastructure to treat constituents most in need – persons living with serious mental illness and substance use disorders.


This extreme circumstance has brought to light the need for enhanced federal direction as to when and how a state can freeze Medicaid payments to providers.  In response to the crisis in care access that occurred in their home state, both Senators Martin Heinrich (D-NM) and Senator Tom Udall (D-NM) along with Representatives Ben Luján (D-NM) and Michelle Lujan Grisham (D-NM) introduced the Medicaid Program Integrity Act of 2016.  The bill, if enacted, would establish due process rights for health care providers, clarify language that allows states to cease Medicaid funding due to “credible allegations of fraud,” and impose safeguards to permit the renewal of Medicaid funding at specified points throughout the investigation process.  The National Council worked with these offices on this legislation and looks forward to its consideration and passage.