HEALTH

Wisconsin investigators found massive fraud in a Medicaid-funded program. Here's what you need to know

Mary Spicuzza Cary Spivak Drew Dawson
Milwaukee Journal Sentinel

Wisconsin is cracking down on prenatal care coordination fraud after millions of dollars meant to prevent infant mortality actually went into the pockets of fraudulent operators.

A 2022 Milwaukee Journal Sentinel investigation illuminated the problem at the state level, highlighting how providers repeatedly took advantage of the system.

For those who have used, are using, or plan to use prenatal care coordination services in Wisconsin, here's what you need to know.

What are prenatal care coordination companies (PNCCs)?

Prenatal care coordination is a Wisconsin Medicaid and BadgerCare Plus benefit that helps pregnant people get the supports and services they need during and right after pregnancy, according to the Wisconsin Department of Health Services. This includes connecting pregnant people to medical, social and educational services to improve birth outcomes.

The program is meant to help lower Wisconsin's infant mortality rates. The state has long had one of the nation's worst records for Black infant mortality.

You can learn more about PNCCs in Wisconsin on the DHS website.

What do PNCC services include?

According to the state DHS, prenatal care coordination services might include:

  • Creating a care plan that has supports and services based on your needs
  • Meeting regularly to go over your care plan and make changes 
  • Scheduling health care appointments  
  • Connecting you to community-based services such as FoodShare, housing, and transportation
  • Going to classes on health education and nutrition - individual or small group

Why is the state cracking down on PNCC providers?

A state investigation uncovered that millions of dollars meant to prevent infant mortality was actually going into the pockets of fraudulent operators.

"These women and children deserve better," said Kirsten Johnson, who became the head of the state Department of Health Services earlier this year.

More:Wisconsin officials crack down on fraud-ridden infant mortality program

Johnson told the Journal Sentinel that PNCC claims from the end of May through October this year totaled over $2 million, but only $20,000 — or just 1% — of those claims were legitimate.

The crackdown comes in the wake of a 2022 Journal Sentinel investigation that revealed massive fraud in the program.

Has anyone been charged for the fraud in Wisconsin?

Yes. Two former PNCC owners, Markita Barnes and Precious Cruse, are facing felony charges for fraud in federal court.

Barnes, who was the owner of one of Wisconsin's largest prenatal care companies, is charged with improperly pocketing $2.3 million in Medicaid money.

Cruse is charged with with illegally taking more than $700,000 while running her own PNCC.

Both have denied any wrongdoing.

Besides Barnes and Cruse, the state health department's Office of the Inspector General has referred 20 Medicaid providers to the state Department of Justice's Medicaid Fraud Control Unit for "engaging in suspected fraudulent activity" involving false claims.

What else is Wisconsin doing about PNCC fraud?

The state Department of Health crackdown includes:

  • Conducting a comprehensive review of all current providers, including every submitted claim.
  • Seeking authority from federal officials to only enroll new PNCC providers "who do not have major indicators of fraud." That includes blocking former employees of fraudulent PNCCs from opening their own operations.
  • Implementing a "payment integrity review" for all claims submitted to the child care coordination program, a sister program that provides services for children who age out of the PNCC program.

Is infant mortality a problem in Wisconsin?

Yes. Black babies in Wisconsin are three times more likely to die than white babies, and Black women here are five times more likely to die during pregnancy and in childbirth than white women, statistics show.

"Wisconsin's disparities in maternal and infant health outcomes are preventable and unjust," Johnson said in a statement. "We have worked to identify and hold accountable bad actors to ensure Wisconsin women and children receive the services they need and deserve for which Medicaid has been billed."

How can you find a PNCC provider in the state?

To learn about local prenatal care coordination providers, contact the Well Badger Resource Center:

How can you report suspected PNCC fraud?

The state health department says anyone who suspects fraud, waste, or abuse of public funds can contact the Office of the Inspector General through the fraud hotline at 877-865-3432 or use the DHS fraud reporting webpage.