Preventing and Recognizing Medicaid Fraud and Abuse

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.


We Have A Statewide Presence

Regional Offices:Capital DistrictWestern NY (2)Central NYWestchesterNew York City (2)Long Island


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


Executive Office: James C. Cox, Medicaid Inspector General Bureau of Agency Coordination & CommunicationBureau of ComplianceBureau of Risk ManagementBureau of Quality Assurance

OMIG Administration


Office of Counsel

Office of Administration

Division of Medicaid Investigations

Division of Medicaid Audit

Division of Technology and Business Automation

OMIG’S Organizational Structure


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)


Coordination between the divisionsCombines staff knowledgeable in their field

Improved efficiency

More thorough reviews and investigations

Reduced time to conclusion

Why Business Line Teams


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


Provider and Undercover Investigations UnitRecipient Fraud UnitPharmacy Investigations UnitAdministrative Remedies UnitEnrollment and Reinstatement UnitRecipient Restriction Unit

Division Structure


“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?


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


“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?


Services Not RenderedUnnecessary ServicesUnbundlingKickbacks and BribesUpcoding

Types of Medicaid Fraud


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


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


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


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


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


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?


Eligibility

Drug diversion

Card lending

Selling drugs, supplies, or equipment obtained with Medicaid funds

Types of Recipient Fraud


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


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


Thanks for listening

Thanks for your diligence and achievements in serving those in your community

Thanks for working to improve program integrity

Thank You


We Want to Hear from YOU

Our new, improved Web site: www.omig.ny.govJoin our ListservFollow us on Twitter: @NYSOMIGDedicated e-mail: [email protected] than 4,000 final audit reportsAudit protocolsAnd much, much more!


Contact Information

Christopher BedellMedicaid Investigator 2

New York State Office of the Medicaid Inspector General

250 Veterans Memorial Highway, Room 4A12Hauppauge, NY 11788

[email protected]

Preventing and Recognizing Medicaid Fraud and Abuse

Documents

Transcript of Preventing and Recognizing Medicaid Fraud and Abuse