New fraud detection requirements — and opportunities — for Medicaid

Under a proposed rule from the Centers for Medicare & Medicaid Services (CMS), states would have the authority to impose a moratorium on provider types, as long as they can show this will not impact access to care.

This requirement will be very helpful to states, according to Ann Page, RN, MPH, director of Health Care Accountability Administration for Washington DC Medicaid.

"We and other states are sometimes inundated, because health care can sometimes be very profitable," says Ms. Page. "You may have more people trying to get into the program than you actually need."

At a time when states are struggling with budget deficits and layoffs, Ms. Page says that "it's a challenge to run an efficient program when you have more providers than you have people who can monitor them."

Under the Patient Protection and Affordable Care Act, each state Medicaid program was required to contract with one or more Recovery Audit Contractors (RACs) to identify underpayments and overpayments to providers and recoup overpayments.

As a result of these changes and other requirements in health care reform, Ms. Page says that states will have to put new operational procedures in place that weren't mandated before. "That certainly is going to challenge states in a time of pressing budgets, but maybe this will save us heartache down the road," says Ms. Page. "We can put the safeguards in up front, and hopefully avoid fraud and waste."

Up-front safeguards are key

Ms. Page notes that it's much harder to "pay and chase" than to "cost-avoid." "It's real hard to pay a provider and chase them down for money owed," she says. "We do have providers who we have sought prosecution on, and they disappear. We don't get that money back."

For this reason, says Ms. Page, the department has set out to limit opportunities for wrongdoing. "I think that's the intent of the federal legislation — to identify best practices and sound practices that all states should have in place," she says. "These will serve as safeguards to prevent fraud and abuse from happening in the first place."

Ms. Page notes that the legislation requires more disclosures of owners, managing employees, and others with financial interest in companies. This information, says Ms. Page, will allow states to check federal databases for the names of people who are not allowed to do business because of past wrongdoing.

"It will require more work on the part of states, and more work on the part of providers, because they will have to disclose more," adds Ms. Page. "The purpose is to screen for bad apples who have done wrong in the past, and to keep those parties from abandoning business A and reconfiguring themselves as business B."

New RAC requirement

Ms. Page says that DC Medicaid's compliance with the RAC requirement "will be a supplement to the work we do in-house. There will be more resources brought to bear on this."

Providers will be facing more review than they have in the past, says Ms. Page, but they stand to benefit fiscally over the long term. "Medicaid can't always pay providers as much as it would like," she says. "To the extent that we are not making fraudulent payments, that means we have that much more in our budget to reimburse all of our providers."

Mike Blackburn, bureau chief of Florida's Agency for Health Care Administration's Medicaid Program Integrity, says, "One thing that will present a challenge is the expansion of Medicaid and the number of recipients expected to be brought in to the program."

As for the CMS proposed rule, Mr. Blackburn says "there are a few things that affected us, and some things that we were already doing that were reinforced." The Florida Medicaid Program did have to implement the national Correct Coding Initiatives, and the edits are now up and running, says Mr. Blackburn.

For the RAC requirement, Mr. Blackburn says that Florida already had some appropriation language requiring the program to do a contingency-based contract for a post-payment auditor. "So, we had that already under way. With some very small modifications, we will be able to meet that requirement without any problems," says Mr. Blackburn.

Although Florida already had the field available for the National Provider Identifier (NPI), it had not taken the steps to require that in order to pay a claim.

"We did have the capability to record the number," Mr. Blackburn explains. "We were just not denying claims if we didn't have it and were allowing Medicaid providers to submit their regular Medicaid ID." As of Jan. 1, 2011, an NPI number must be on a provider-submitted claim in Florida, or it will deny.

The agency was already required to terminate any provider who had been terminated by another state Medicaid program, and exclude providers if they were already on a federal exclusion list, says Mr. Blackburn.

Mr. Blackburn notes that payment suspensions for fraud investigations are now a federal requirement, while this was previously done at the state's discretion. "We did have some leeway," he explains. "If we thought payment should be suspended, we certainly had the authority to do that. Now, if we make a fraud referral, we have to suspend payment."

Contact Mr. Blackburn at (850) 412-3977 or and Ms. Page at (202) 478-5792 or