California Medicaid saving millions with progressive anti-fraud efforts

California's Department of Health Care Services' (DHCS) anti-fraud program is regarded among the top programs in the nation, reports department spokesman Anthony Cava.

A September 2010 proposed rule from the Centers for Medicare & Medicaid Services (CMS) would strengthen fraud oversight in Medicare, Medicaid, and the Children's Health Insurance Program.

"CMS has approved and been supportive of our anti-fraud efforts, and through its recently proposed rule is allowing other states to follow California's lead," says Mr. Cava. "We currently practice all of the fraud prevention measures specified in the rule." Here are some current practices, according to Cava:

• Usage trends are analyzed by beneficiaries and providers, to confirm that services are not being obtained or provided in a fraudulent manner and that services claimed have been delivered.

Currently, DHCS is engaged in sending 500 beneficiary contact letters to determine if these beneficiaries received a wheelchair, and if it is the one for which DHCS paid. "This practice has been fruitful," says Mr. Cava. "Based upon beneficiary response, DHCS may further investigate physicians and durable medical equipment providers."

• The provider enrollment process was tightened by developing new regulations that provide specific requirements for enrollment.

These include requiring providers to have an established place of business, developing new applications that obtain additional information about the provider and the business, and developing new provider agreements with clear language regarding Medi-Cal program compliance.

"One of the key elements of the enrollment and re-enrollment efforts is a background check. An onsite review of providers by DHCS Audits & Investigation is done prior to enrollment," says Mr. Cava.

• Focused reviews are conducted of provider types.

In September 2006, 2,000 pharmacies throughout California were visited and reviewed for compliance by DHCS staff. Similar reviews were done of Adult Day Health Care providers, durable medical equipment suppliers, and physicians billing for intrauterine devices.

"DHCS is constantly striving to improve its anti-fraud efforts by maintaining a highly trained staff, keeping abreast of the latest fraud trends and schemes, and utilizing the latest technologies and techniques designed to detect, identify, and eliminate fraud, waste, and abuse within its programs," says Mr. Cava.

Fraud prevention tool

The Medi-Cal Payment Error Study (MPES) is a fraud prevention tool used to continuously assess and monitor emerging trends, make informed decisions on the allocation of fraud control resources, and identify where the Medi-Cal program is at greatest risk for payment errors.

"The primary objective of MPES, implemented annually since 2004, is to detect, identify, and prevent fraud and abuse in the Medi-Cal program, gauge the seriousness of the problem, and develop appropriate fraud control strategies," says Mr. Cava.

MPES 2007, the most recent report, found that 93.44% of reimbursements paid to fee-for-service Medi-Cal providers in 2007 were billed appropriately and paid accurately. This represents an improvement from the 92% accuracy rate of 2006.

"The 6.56% error detected in the 2007 MPES represents a $1.05 billion potential loss to the program," reports Mr. Cava. "Of the total claims reviewed, 2.53%, or $405 million, were found to have characteristics of potential fraud. This is lower than the 2.75% found in the 2006 study, which represented $445 million in payments."

DHCS performs investigational and routine field compliance audits to identify provider claim errors, take appropriate corrective actions, and apply appropriate sanctions. Patterns are reviewed, cases are developed, and sanctions are placed on providers who submit claims with errors or characteristics of fraud.

"Currently, all errors identified in MPES 2007 are being reviewed to determine if follow-up reviews on audits should be conducted," says Mr. Cava.

Contact Mr. Cava at (916) 440-7660 or anthony.cava@dhcs.ca.gov.