A record sum of $122.8 million has been recovered by the state comptroller’s Medicaid Fraud Division this past fiscal year, according to its annual report released last week.
The sum, which was identified as improperly paid funds, was returned to both the state and federal budgets (each government entity pays 50 percent of Medicaid). Additionally, an estimated $392 million in other potential Medicaid expenses were avoided through proactive antifraud efforts, and 60 providers were found to be ineligible and forced out of the program.
Data mining and audits are used to detect indications of fraud and abuse, as well as duplicate, inconsistent, or excessive claim payments, according to the report. For instance, the office’s data-mining group referred 65 cases of anomalous claims behavior to the audit and investigations units in 2013.
These cases can often lead to the discovery of further abuses, such as the case of a nurse practitioner who billed for hours beyond the traditional workday on 300 occasions. Once an investigation was launched, it was determined that multiple unlicensed providers from the same office were improperly billing the Medicaid program.
Another way the office learns of potential abuse is through its hotline and website, in addition to other agencies. The comptroller’s office followed up on 558 tips in fiscal 2013. The Investigations Unit opened 294 cases and made 45 referrals to other agencies, including the state Attorney General’s office.