D.C. Health Alliance Faulted on Eligibility Control

The D.C. Healthcare Alliance, the city's safety net for poor, uninsured residents, might have allowed hundreds of ineligible people to receive benefits because of inadequate or nonexistent controls, according to a 17-month audit released yesterday.

The review identified thousands of records that appeared to be duplicate entries or were rife with inaccurate or missing data. It concluded that the information and documents that applicants presented were routinely not confirmed.

Whether driver's licenses, home addresses or employment income, the lack of verification meant that applicants could "misrepresent facts to obtain eligibility and the misrepresentation may go undetected."

From June 2006 to mid-November 2007, the period covered by the audit, some addresses showed up repeatedly. Thirty-three recipients claimed to live at one location. A large apartment building at an address might explain such high numbers, or fraud could be the reason, the audit said. In many cases, the letters applicants used to prove their residency in the District were signed by relatives or friends.

The audit also found many cases in which multiple payments were made to the same person or payments were issued after an individual's eligibility had expired. Those frequently involved men and women who should have been transferred onto Medicaid and Medicare when they turned 65, including three dozen people who remained in the Alliance despite being in their 70s.

The review, conducted at the Health Department's request by the public accounting and management firm Bert Smith & Co., includes numerous recommendations dealing with increased staffing, tougher documentation requirements and more timely investigations. Responsibility for changes will fall to the city's Income Maintenance Administration, the agency that determines eligibility.

More than 45,000 District residents are part of the Alliance, pushing its annual cost to $129 million. The program was created after D.C. General Hospital closed in 2001, but the number of residents enrolled has increased sharply in the past two years. Participants are 19 and older, uninsured or underinsured, and ineligible for other public-assistance programs. Their annual income cannot exceed 200 percent of federal poverty levels, or about $21,000 for a person living alone.

In response to the audit, Mayor Adrian M. Fenty (D) and Carlos Cano, interim director of the Health Department, released a plan yesterday to close loopholes and ensure that only qualified residents receive coverage. Among its measures: additional staff training on how to screen and enroll beneficiaries; more community education on the program's rules; and prompt transfers of seniors to Medicare and Medicaid, programs that are supported by federal funds.

The Income Maintenance Administration also hopes to work more with other jurisdictions to identify, through database comparisons, nonresidents seeking District benefits, the plan says.

"The District has made great strides in reducing barriers for enrollment for these populations and will continue to maintain our promise to provide health-care services to all District residents," Fenty said.