Medicaid combats fraud with better screening and more targeted audits

Mike Blackburn, bureau chief of Florida's Medicaid Program Integrity, says that the agency has multiple fraud prevention initiatives under way, "though it may be too early to call them complete successes." He says that the post-payment auditor that will meet the RAC [Recovery Audit Contractors] requirement will be a big help in supplementing what the Medicaid Integrity Group is able to do.

"We are also enhancing our background screening and working with other parts of the agency to do that," reports Mr. Blackburn. The Medicaid Integrity Group is working with Health Quality Assurance, which licenses medical facilities; the Department of Health, which licenses Medicaid practitioners; and the Florida Department of Law Enforcement (FDLE), which does background screening.

"We are looking to enhance that process. We are even looking at retaining fingerprints for up to five years," says Mr. Blackburn. "So, even if they pass the initial screening, if they are subsequently [convicted], FDLE will alert us to that conviction."

Currently, whether it's a Medicaid fraud control unit arrest, a state attorney's arrest, or a local sheriff's arrest, alerting the Medicaid Integrity Group about a conviction is a manual process, says Mr. Blackburn, "and that doesn't always work."

Better auditing ability

"Making sure we target our audits appropriately is always a challenge," says Mr. Blackburn. "We have a Request for Information on the street right now designed to provide the state with information regarding options for prepayment use of technology to detect and deter Medicaid fraud, abuse, and overpayments. If we are able to procure some advanced detection technologies, we will be able to get more 'bang for our buck,' so to speak, for the time it takes us to do the audits."

This technology will help to identify a specific provider who is an outlier, or whole provider categories or service types that show a high risk of potential for overpayment, says Mr. Blackburn.

Mr. Blackburn notes that "there is a big provider and recipient population down in Miami, and that is where a lot of the fraud is occurring."

Two pilot projects specifically targeting fraud in Miami-Dade County were implemented on July 1, 2010. Both involve home health agencies, which were identified as a particular service type that needed more scrutiny, says Mr. Blackburn.

The "Telephony" project requires home health aides to call in to a vendor when they arrive, he says, and again when they leave. "They verify the duration of the visit, and that the individual is indeed there providing services," says Mr. Blackburn.

The project utilizes Interactive Voice Response Authentication technology to verify the presence of a direct care home health service provider in the recipient's home. The nurse or home health aide must call a designated toll-free number at the beginning and end of each home health visit and repeat a standard phrase for voice verification.

"The system will verify that the voice recorded during the check-in and check-out calls matches the voice previously recorded on their system," says Mr. Blackburn.

Face-to-face assessments

The other pilot project involves an on-site care monitoring program for home health-related services. "The purpose of the project is to identify potential overutilization and potential fraud or abuse of Medicaid services, by ensuring that the level of services provided match the needs of the recipients," says Blackburn.

Registered nurses do a minimum of 250 home visits each month to perform a face-to-face assessment of the recipient. The results of the assessment are compared against documentation provided by the home health agency and/or the prescribing physician during the prior authorization process, explains Mr. Blackburn.

Based on the outcome and findings from the home visit, the vendor may determine that a more intensified review is required, says Mr. Blackburn, which could include consultation with the physician ordering the services, review of the recipient's medical records, or an on-site visit to the home health agency performing the services.

Four percent of the face-to-face assessments done in November 2010 resulted in a recommendation to reduce or terminate services, reports Mr. Blackburn, with 21 referrals made to the Bureau of Medicaid Program Integrity.

Recoup funds owed

"Even before the recent federal interest in fraud and abuse prevention, our agency has always taken an aggressive approach to preventing fraud and abuse," says former Alabama Medicaid Commissioner Carol Steckel, who also serves as president of the National Association of Medicaid Directors. "Still, we always believe we can do more."

Ms. Steckel reports that the Alabama Medicaid program is taking an innovative approach, by embarking on a two-year contract with a company to identify funds that may be owed to the state by conducting a focused post-payment claims review.

"The company only receives payment when funds are recovered, so it is a win-win for the state and the company," she says. Alabama Medicaid will work with the company to review claims filed for the past two years by all provider groups in the state of Alabama, says Ms. Steckel, including hospitals, physicians, dentists, pharmacies, durable medical equipment companies, and home health care providers.

"The goal of this agency is to make sure every public dollar is properly spent to improve the health of the people of Alabama," says Ms. Steckel. "A contingency-based contract ensures that Alabama taxpayers are only paying for results."

Alabama Medicaid will be provided with a full range of fraud, waste, abuse, and overpayment identification and collection tools and services, including data mining, analytics, and detection algorithms, says Ms. Steckel.

This will bolster Alabama Medicaid's comprehensive Program Integrity initiative, says Ms. Steckel, which includes these components:

• a review of the list of sanctioned individuals, to ensure they are not working in any capacity for an entity that receives payments from Medicaid or Medicare;

• a more rigorous review of any provider enrollment application in which the applicant has previously been sanctioned or suspended;

• a requirement that any Medicaid beneficiary who has his or her eligibility reinstated after being suspended from the Medicaid program for drug-related fraud, abuse, or misuse of benefits will be placed in the restriction program and have his or her utilization of benefits monitored for one year;

• a review of new applications of durable medical equipment providers prior to enrollment, to ensure they have a legitimate office and staff;

• measurement of the accuracy of the agency's eligibility determination process. "This consistently out-performs the national average of 3%," reports Ms. Steckel. "In fact, the agency's most recent error rate was only one-half of 1% for the year."