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Preventing and Recognizing Medicaid Fraud and Abuse. Medicaid Investigator 2, Christopher Bedell May 10, 2013 NEW YORK, NEW YORK. MISSION STATEMENT. - PowerPoint PPT Presentation
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Fighting Fraud. Improving Integrity and Quality. Saving Taxpayer Dollars.
Fighting Fraud. Improving Integrity and Quality. Saving Taxpayer Dollars.
MISSION STATEMENT
Our mission is to enhance the integrity of the New York State Medicaid program by preventing and detecting fraudulent, abusive, and wasteful practices within the Medicaid program and recovering improperly expended Medicaid funds while promoting high-quality patient care.
Fighting Fraud. Improving Integrity and Quality. Saving Taxpayer Dollars.
We Have A Statewide Presence
Regional Offices:Capital DistrictWestern NY (2)Central NYWestchesterNew York City (2)Long Island
Fighting Fraud. Improving Integrity and Quality. Saving Taxpayer Dollars.
Costs Tax Payers > $52 BillionNearly 5 Million RecipientsOver 60,000 Active ProvidersProcesses over 350 Million Claims Per YearMedicaid is the Payer of Last Resort
Facts About NY State Medicaid
Fighting Fraud. Improving Integrity and Quality. Saving Taxpayer Dollars.
Executive Office: James C. Cox, Medicaid Inspector General Bureau of Agency Coordination & CommunicationBureau of ComplianceBureau of Risk ManagementBureau of Quality Assurance
OMIG Administration
Fighting Fraud. Improving Integrity and Quality. Saving Taxpayer Dollars.
Office of Counsel
Office of Administration
Division of Medicaid Investigations
Division of Medicaid Audit
Division of Technology and Business Automation
OMIG’S Organizational Structure
Fighting Fraud. Improving Integrity and Quality. Saving Taxpayer Dollars.
Managed Care Medical Services in an Educational Setting Home and Community Care Services Hospital and Outpatient Clinic Services Mental Health, Chemical Dependence, and
Developmental Disabilities Services Pharmacy and Durable Medical Equipment Physicians, Dentists and Laboratories Residential Health Care Facilities Transportation
Business Line Teams (BLTs)
Fighting Fraud. Improving Integrity and Quality. Saving Taxpayer Dollars.
Coordination between the divisionsCombines staff knowledgeable in their field
Improved efficiency
More thorough reviews and investigations
Reduced time to conclusion
Why Business Line Teams
Fighting Fraud. Improving Integrity and Quality. Saving Taxpayer Dollars.
Investigate fraud, waste and abuse in the Medicaid program
Deter improper behavior
Ensure that Medicaid recipients receive quality care
Foster cooperation with internal and external partners
Division Mission
* PI-Program Integrity
Deterrence
Cooperation PI*Qualityof Care
Fraud, Waste& Abuse
Fighting Fraud. Improving Integrity and Quality. Saving Taxpayer Dollars.
Provider and Undercover Investigations UnitRecipient Fraud UnitPharmacy Investigations UnitAdministrative Remedies UnitEnrollment and Reinstatement UnitRecipient Restriction Unit
Division Structure
Fighting Fraud. Improving Integrity and Quality. Saving Taxpayer Dollars.
“Waste and abuse” are defined as practices that are inconsistent with professional standards of care; medical necessity; or sound fiscal, business, or medical practices; and that constitute an overutilization of Medicaid-covered services and result in an unnecessary cost to the Medicaid program
What is Medicaid Waste and Abuse?
Fighting Fraud. Improving Integrity and Quality. Saving Taxpayer Dollars.
A provider ordering or performing unnecessary tests
Ordering unnecessary transportation
Ordering unnecessary durable medical equipment
Waste and abuse can lead to fraud
Types of Waste and Abuse
Fighting Fraud. Improving Integrity and Quality. Saving Taxpayer Dollars.
“Fraud means an intentional deception or misrepresentation made with the knowledge that the deception could result in an unauthorized benefit to the provider or another person and includes the acts prohibited by section 366-b of the Social Services Law.” – 18 NYCRR 515.1(b)(7)
What is Provider Fraud?
Fighting Fraud. Improving Integrity and Quality. Saving Taxpayer Dollars.
Services Not RenderedUnnecessary ServicesUnbundlingKickbacks and BribesUpcoding
Types of Medicaid Fraud
Fighting Fraud. Improving Integrity and Quality. Saving Taxpayer Dollars.
Verify: Did you actually receive the service? Did it take place on the date noted on the EOB?
Is the provider (e.g., physician, therapist, dentist, etc.) actually the person you saw?
OMIG sends out explanation of benefits (EOBs) to recipients
Were you transported from point A to point B on the date noted?
Services Not Rendered
Fighting Fraud. Improving Integrity and Quality. Saving Taxpayer Dollars.
Examples:Restorative dental care for people who have no teethMonthly capitation fees for deceased managed care patientsPre- and post-natal care for girls under the age of 10 or women over the age of 55Custom-fitted shoes for double amputees
Unnecessary Services
Fighting Fraud. Improving Integrity and Quality. Saving Taxpayer Dollars.
Fraud schemes called “unbundling” involve instances in which a provider bills separately for the component parts of a product or service, resulting in a significantly larger payment to the provider. For instance, a durable medical equipment provider company was found to have billed for the component parts of a wheelchair separately, thus receiving four or five times more than if the wheelchair alone had been billed as a single item.
Unbundling Supplies and/or Services
Fighting Fraud. Improving Integrity and Quality. Saving Taxpayer Dollars.
Providers cannot receive compensation in goods, money, or services in exchange for referring Medicaid recipients to other providers
It is illegal to pay a Medicaid recipient a fee to go to a medical practice to receive services
It is illegal to pay a “finder” to convince Medicaid recipients to choose a specific Medicaid provider
Kickbacks and Bribes
Fighting Fraud. Improving Integrity and Quality. Saving Taxpayer Dollars.
You are medical billers and coders. You know that you cannot do things such as:Bill for a full stroke when a Medicaid recipient (or anyone, for that matter) has a transient ischemic attack (TIA) (mini-stroke)Bill for a Cesarean section when the patient had a vaginal delivery
Upcoding
Fighting Fraud. Improving Integrity and Quality. Saving Taxpayer Dollars.
A recipient knowingly makes or causes to be made a false or misleading statement or representation for use in obtaining benefits from the medical assistance program
What is Recipient Fraud?
Fighting Fraud. Improving Integrity and Quality. Saving Taxpayer Dollars.
Eligibility
Drug diversion
Card lending
Selling drugs, supplies, or equipment obtained with Medicaid funds
Types of Recipient Fraud
Fighting Fraud. Improving Integrity and Quality. Saving Taxpayer Dollars.
Providers: Impose Sanction
ExclusionCensure
Termination Payment withholdsReferrals to the Attorney General’s Medicaid Fraud
Control Unit and/or other law enforcement entities.Recipients:
Criminal charges/prosecutionMedicaid restriction/administrative remedies
OMIG Actions for Fraud, Waste and Abuse
Fighting Fraud. Improving Integrity and Quality. Saving Taxpayer Dollars.
Majority of providers are honest Criminals have infiltrated the health insurance
system Medicaid is part of the health insurance system Bad providers prey on the most vulnerable Everyone is a potential victim Be a “HERO”: If you see something, say
something
Operating Principles
Fighting Fraud. Improving Integrity and Quality. Saving Taxpayer Dollars.
Thanks for listening
Thanks for your diligence and achievements in serving those in your community
Thanks for working to improve program integrity
Thank You
Fighting Fraud. Improving Integrity and Quality. Saving Taxpayer Dollars.
We Want to Hear from YOU
Our new, improved Web site: www.omig.ny.govJoin our ListservFollow us on Twitter: @NYSOMIGDedicated e-mail: information@omig.ny.govMore than 4,000 final audit reportsAudit protocolsAnd much, much more!
Fighting Fraud. Improving Integrity and Quality. Saving Taxpayer Dollars.
Contact Information
Christopher BedellMedicaid Investigator 2
New York State Office of the Medicaid Inspector General
250 Veterans Memorial Highway, Room 4A12Hauppauge, NY 11788
631-952-6282Christopher.Bedell@omig.ny.gov
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