Archive for Medicaid
The Utah Medicaid program has significant room for improvement when it comes to program integrity, according to a report released by the Utah Office of Legislative Auditor General.
- Prior authorization. The report says that authorization for services prior to their implementation could be a great way to prevent overutilization of Medicaid services; however the reports says the state’s Bureau of Program Integrity does not properly use this strategy. The report estimates a 1% change in the approval rate for the prior authorization process could save $700,000 ($210,000 in state dollars).
- Improved recovery effort. The report suggests the state step up its fraud, abuse, and waste recovery effort. The report estimates a 3% increase in this area could save $20.2 million ($5.8 million in state dollars) over time.
Community Health Systems Inc., a Tennessee-based heathcare corporation, allegedly made illegal donations to New Mexico counties that contain three Community Health hospitals, according to an August 10
Albuquerque Journal article.
The suit claims Community Health made donations to the counties to subsidize the state’s Medicaid contributions. The counties then allegedly turned that money over to the state as their Medicaid contribution. Because the federal government pays three times what the state pays for Medicaid, Community Health allegedly received a return on their investment plus triple the amount donated.
The whistleblower suit was filed in 2005 by a former employee, Robert C. Baker. According to the article, Baker learned about the scheme when he took over as revenue manager for Eastern New Mexico Medical Center in Roswell.
Nearly 500 Medicaid audits are under way in 17 states, and the program will roll out to the entire country through the end of the year, according CMS representatives who spoke on the Medicaid Integrity Program Special Open Door Forum on July 15.
CMS hopes to identify additional contractors within the next few days. These contractors, known as Medicaid Integrity Contractors, are firms CMS has chosen to carry out the following Medicaid Integrity Program goals:
- Review provider actions to determine whether fraud, waste, or abuse may have occurred
- Audit provider claims
- Identify overpayments
- Educate those involved in Medicaid administration, providers, managed care entities, beneficiaries and others with respect to payment integrity and quality of care
There are three types of contractors: Review, audit, and education MICs. The review MICs analyze data and identify issues to pass on to audit MICs to pursue, according to CMS. Education MICs will educate providers and others on Medicaid payment integrity and quality of care.
Read the rest of this post, or share your thoughts on this topic.
This article is adapted from HCPro’s newest resource for hospital case managers—http://blogs.hcpro.com/casemanagement/—a free blog dedicated to connecting hospital case managers to industry pacesetters, peers, and best practices.
Browse more blog posts at www.CaseMangementMentor.com.
State Medicaid Fraud Control Units (MFCU) recovered $1.3 billion in court-ordered restitution, fines, civil settlements, and penalties for fiscal year 2008, according to an August 7
Office of Inspector General (OIG) report.
MCFUs also obtained 1,314 convictions; achieved 971 civil settlements and/or judgments; and excluded 755 providers from participation in the Medicare, Medicaid, and other Federal health care programs in FY 2008, the report stated.
The mission of the MFCUs is to investigate and prosecute Medicaid provider fraud and patient abuse and neglect. Forty-nine states and the District of Columbia have MFCUs—North Dakota does not have an MFCU.
The report highlights a settlement between the New York MFCU and Staten Island University Hospital (SIUH) and SIUH Systems, Inc., in which SIUH agreed to pay the Medicaid program $24.8 million. The settlement resolved allegations that SIUH Systems billed Medicaid for detoxification treatment provided in a special unit of the hospital without a state-issued certificate of operation.
The Obama administration has made it clear that cracking down on healthcare fraud and abuse is a priority, and the latest version of the America's Affordable Health Choices Act of 2009 includes an additional funding increase to ensure that government money is not lining the pockets of fraudsters.
That increase in enforcement will be essential if more people are covered under a government system, according to Robert A. Wade, Esq., partner at Baker & Daniels, LLP, in South Bend, IN.
Wade says he would expect an uptick in fraud and abuse cases if the reform passes simply because more people will be covered and more money will funnel through the system. If the federal program covers more people, more claims would fall under the False Claims Act and Stark Law.
Some opponents of a government-run healthcare system cite the high level of fraud and abuse in the Medicare and Medicaid programs as a sign that the government is incapable of running an efficient system. However, experts argue that government programs are no more susceptible to fraud and abuse than private insurers.
"If a physician or [healthcare] entity has the capacity to commit fraud, they will do it regardless of which bucket they are taking from," said Wade.
A report from the George Washington University Medical Center in Washington D.C. titled “Health Insurance Fraud: An Overview” concurs.
"What is absolutely clear from virtually every reliable source on the subject is that healthcare fraud is a systemic problem affecting public and private insurers alike, in the individual market, the employer-sponsored group market, and public programs," the report stated.
Authors of the report, Sara Rosenbaum, Nancy Lopez, and Scott Stifler, said the reason the public is more aware of Medicare and Medicaid fraud is because the government is required to tell taxpayers where their money is going. Most recently, Office of Inspector General Chief Counsel
Lewis Morris told Congress that the United States lost $60 million to healthcare fraud in 2008, which was 3% of the government's budget.
Private insurance companies are not obligated to release such numbers so fraud involving those companies stays out of the headlines. The amount of money private insurers lost to fraud is reported to the board of trustees, not the public.
"[Healthcare fraud enforcement] has been a theme we have seen in the president's budget and Medicare rule making," says Ed Dougherty, senior vice president of B&D Consulting. "I would say regardless of what happens in healthcare reform, there will be increased focus in all sites of service."
Medicaid's "cumbersome" policies often lead to patients not getting or filling their prescriptions, receiving important diagnostic tests, or managing their chronic disease, which will lead to more costs down the road, according to a new report released by the Association for Community Affiliated Plans.
The Medicaid system, which varies by state, requires beneficiaries to show proof more than once a year that they and their children are still eligible for the public program. This leads to many falling off the rolls, which is a cycle that interrupts their continuity of care and jeopardizes their health.
Additionally, with so many people "churning," which means dropping out and back in to the Medicaid rolls every few months, the federal goal of measuring the quality of the patient care has become extremely problematic if not impossible, according to the group, which represents 42 nonprofit safety-net health plans serving six million beneficiaries in 23 states.
Read the full story by HealthLeaders Media's Cheryl Clark.
CMS is hosting a Special Open Door Forum for providers on the Medicaid Integrity Program (MIP) provider audit program, today, Wednesday, July 15.
According to CMS, the call will include information on:
- The MIP audit process
- Audit timelines
- Web site information
- Future meetings/calls
There will also be a Q&A period on the call so participants can ask questions.
The call will be held Wednesday, July 15 from 1:00 p.m.– 2:30 p.m. Eastern. (Participants may begin dialing in 15 minutes prior to the start of the call.)
The dial-in information is as follows:
Dial: 1-800-837-1935
Reference Conference ID#: 17763217
CMS will post an audio recording and transcript to the Special Open Door Forum Web site for 30 days beginning July 24.
Click here for more information on the Open Door Forum call.
Have you had experience with Medicaid Integrity Program audits? Is so, e-mail Andrea Kraynak, CPC-A, managing editor for HCPro at akraynak@hcpro.com. There may be an opportunity for you to participate in a paid audio conference on this topic.
On July 9, California authorities arrested 20 individuals believed to be involved in a Medicaid fraud scheme that defrauded the Medi-Cal program of allegedly $4.6 million, according to
a Department of Justice (DOJ) release.
The most recent arrests bring the total number of defendants connected to the scheme to 42. The DOJ alleges that the 42 defendants and two others conspired to bill the Medi-Cal program for in-home nursing services provided by unlicensed individuals.
The alleged organizer of the ring, Priscilla Villabroza, pleaded guilty to five counts of healthcare fraud last year and admitted that she and others hired unlicensed professionals to provide in-home nursing services to Medi-Cal beneficiaries, many of them children with cerebral palsy or developmental disabilities. Villabroza then billed the program, claiming the unlicensed nurses were licensed vocational nurses (LVN). Villabroza allegedly instructed the unlicensed nurse defendants, some of whom had no medical training, to lie to parents and claim they were LVNs.
According to the DOJ, patients complained about the nurses’ inability to provide care. In one instance, a nurse fled a medical situation, presumably because she was in over her head and unable to administer the proper care.
Training Programs
Audits & Assessments
Regulatory Monitoring
Get blog updates in your e-mail
Subscribe to our free RAC Report e-zine
