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Invest Now in Medicaid Program Integrity

Use What the OIG Pros Use for a Strong ROI

Stephanie Kuhnel's avatar

By: Stephanie Kuhnel

July 13, 2017 | Healthcare and Benefits

It’s no secret – large entitlement programs that aim to provide services to the neediest citizens are vulnerable to fraud, waste, and abuse, collectively known as improper payments. According to the Government Accounting Office, in 2016 approximately 10.5 percent ($36 billion) of federal Medicaid reimbursements were improperi. Since 2008, Medicaid improper payments have totaled $161 billion,ii earning the program the #3 spot on the Office of Management and Budget’s list of high-priority programs.iii

Like other complex law enforcement efforts, the responsibility for fighting Medicaid fraud and abuse is cross jurisdictional. The savviest perpetrators hit multiple programs across state lines, taking advantage of legacy systems that don’t share information easily. However, when agencies work together using the latest technology, they can pull off takedowns that recover millions of dollars.

The return on investment (ROI) speaks for itself:

  • Between FY 2010-2014 the 50 state Medicaid Fraud Control Units (MFCUs), working with their state Medicaid Program Integrity Units, achieved a combined 79 percent conviction rate and recovered $11.1 billion. That equates to more than $1 million per employee, on average, and a tenfold return on every dollar invested. iv
  • The Medicare Integrity Program (MIP) is estimated to return $12 for every $1 invested, with consistent annual savings of over $10 billion.v
  •  In FY 2016 alone, the Health Care Fraud and Abuse Control program, which funds MIP and several cooperating federal agencies, recovered $3.3 billion. vi

End-to-end Program Integrity

Impressive as these returns may be, prevention is the best cure. Better to catch potential criminals before they can act than rely on “pay and chase” efforts after the fact. As the feds are quick to point out, widescale fraud prevention won’t be possible until states act en masse to modernize their enrollment and eligibility systems (E&Es) so they are interoperable and can detect potential fraudsters from entering or reentering the system. 

On the front end, plug-in components to E&Es such as predictive analytics and background investigation tools can identify and reject suspicious providers and patients. During claims adjudication, Medicaid Management Information Systems must run hundreds of prepayment edits in order to flag potentially fraudulent claims, based on provider history, medical necessity, and other checks.

On the back end, fighting healthcare fraud is particularly complex. Successful prosecution begins with a network of investigative case management systems that enables attorneys, auditors, investigators, and medical experts at every level to share data in all formats. MFCUs typically operate out of their state Attorney General’s office, with oversight and funding by the HHS Office of Inspector General (OIG). Integration with disparate criminal justice information systems (CJISs) is essential, but so is integration with other Medicaid Enterprise System (MES) modules. Indeed, a case management system for program integrity such as entellitrak that aligns with the Medicaid Information Technology Architecture 3.0 framework and supports the Seven Conditions and Standards should qualify for 90/10 matching funds from the Centers for Medicare and Medicaid Services.

Experience Counts

entellitrak is relied on to manage fraud and abuse investigations and program integrity audits across the public sector, including by 11 OIGS. It automates much of the time-intensive work involved in fraud investigation, beginning with intake validation and decision to investigate, so cases can be triaged based on estimated recoupments and effort to secure them. Because entellitrak is based on open standards and open architecture, it can seamlessly exchange data with other CJISs and MES modules.

Quantifying ROI for technology can be elusive. Not so with program integrity, especially when it comes to cross-jurisdictional takedowns. Each agency’s share of the pot can more than pay for their investment. Contact me to learn how entellitrak can help your organization fight Medicaid fraud.

About the Author

Stephanie Kuhnel has over twenty years of executive leadership experience across multiple sectors, including public sector, technology, consumer goods, government, law enforcement, and education. In her current position she drives the strategic direction and fosters business development opportunities for MicroPact’s health, human services, and benefits portfolio. Stephanie has a bachelor’s degree in business administration from the University of North Carolina at Chapel Hill and an MBA from Meredith College.

Tyler Technologies is the largest and most established provider of integrated software and technology services focused on the public sector

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