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Medicaid Fraud: Is it Worth States’ Time to Fight it?

Medicaid fraud has been a big problem for years, and as states ramp up for the Affordable Care Act’s Medicaid expansion deadline in 2014, it could become an even bigger one. More enrollees plus more providers equals more fraud potential. When estimates place the amount of Medicaid waste in 2012 at $19 billion for the feds and $11 billion in 2010 for the states, we’re talking real money. Can states really put a lid on fraud? And, more important, is it worth the cost to do so?

The first question can be answered by the Centers for Medicare & Medicaid Services, which recently compiled a list of “noteworthy picks,” or on-the-ground state policies that had succeeded at eliminating fraud. The answer to the second is a bit trickier. But the numbers from three states — California, Florida and New Jersey — suggest fraud prevention pays.

Let’s start with California. Lauded for its prevention measures, the state conducts a “Medi-Cal Payment Error Study” once a year to find patterns that would suggest fraud or waste. Bruce Lim, deputy director of audits and investigations for the Department of Health Care Services, calls the study “our road map.” It focuses on fee-for-service providers, and in 2009, the error study “showed about $1 billion in potential overpayments, which could include administrative and other errors,” Lim says. “Of that $1 billion, there is about $228 million in potential fraud.

“[We are] trying to stop the bleeding instead of the usual pay-and-chase model,” he says. The numbers suggest the state’s strategy is working. In fiscal 2011-2012, fraud prevention had a $445 million “positive impact” in areas such as overpayment prevention ($106 million), cost avoidance ($28 million), cost savings ($47 million) and recovery ($102 million). With a department budget of $75 million, that computes to a return on investment of about 6:1. Lim thinks he can do even better: “I know that with newer technologies and data mining we can do more.”

Florida’s approach is less high tech and more gumshoe. State officials conduct random, unannounced site visits for all kinds of providers, both before contracting with them and after. In one six-month period, officials visited 244 active providers and administered 175 sanctions. Overall, in fiscal 2010-2011 audit recoveries and cost avoidance amounts totaled $90.1 million, yielding an ROI of 6.8:1. “The value [of fraud prevention] is extraordinary,” says Kelly Bennett, Florida’s Medicaid fraud and abuse liaison. “Because we are out there visiting providers, we believe we increase compliance, which equates to cost savings.”

New Jersey has an initiative with the cool, spy-like moniker “Operation X.” The program tries to prevent individuals who have previously engaged in unethical or fraudulent practices from collecting Medicaid in the first place. The office matches information from a federal exclusion database against state wage and labor roles, says Mark Anderson, director of the Medicaid Fraud Division. “The feds give us access to their database, and we see if any of their folks have gotten any money whatsoever in New Jersey. Once matched, we assign an investigator to determine if that person worked at any place with Medicaid funding or services. If so, we seek to recover money from that individual and the places he or she worked, and if he or she was a provider, we try to recover the money.”

This one practice nets anywhere from 50 to 200 leads per month, Anderson says, and about 10 to 12 percent of those get investigated. Most cases settle; in total, Operation X sought or collected $970,000 between June 2009 and June 2011. That goes toward New Jersey’s fraud prevention bottom line, which in fiscal year 2011 totaled about $502 million in recovered and avoided payments on office costs of about $8 million, an ROI of about 6.3:1.

So does fraud prevention pay? As these three states show, it certainly can. The takeaway, however, may be in how its done.

This story was originally written and published by Governing magazine.

Identity Management: A New Way to Fight Health Care Fraud, Waste and Abuse

December 26, 2012 By Clint Fuhrman, National Director of Government Health Care Programs, LexisNexis Risk Solutions

Government health-care fraud, waste and abuse has been a major news story for the past year — and with good reason.

In 2010, the U.S. federal government issued $125 billion in “improper payments,” defined as overpayments, underpayments, inadequately documented payments and fraud. While there are many contributing factors, government agencies don’t always know who they’re dealing with, which can result in the wrong individuals receiving and/or providing benefits. Identity theft is the fastest growing crime in the U.S., and with 30 billion connected devices in use, it can be very difficult to ensure that personal information is kept private. 

When it comes to moving services online to streamline processes, reduce costs and increase convenience and efficiency, government has seized the moment. Unfortunately, the functionality that yields these benefits is what creates challenges for maintaining the integrity of the system.

That said, it is possible to leverage the Internet to its fullest potential, while mitigating negative outcomes. Take the Florida Department of Children and Families, which implemented online self-service portals to augment traditional channels. This move enabled the agency to improve its error rate to -0.5 percent, the best in the nation, while achieving a 250 percent boost in productivity. In fact, 95 percent of clients utilize the online system. Certainly these numbers are impressive, but how are they achieved?

The answer is a robust identity proofing management. Government agencies must invest in identity verification and authentication at the front-end of benefit administration. The right identity-proofing strategy must be anchored by robust master data management and rules-based solutions, as well as comprehensive identity management. This type of rigorous identity management involves two processes:

Verifying, through electronic or manual means, that an individual is who they say they are; andAuthenticating that identity through knowledge-based mechanisms, i.e. questions that only they can answer.

Employing this type of system enables government agencies to mitigate fraud, reduce improper payments, increase service delivery and efficiency, and address privacy concerns.  

Identity management requirements will vary from agency to agency depending on the mission. There is no one-size-fits-all strategy. The mission of a federal agency that provides disaster relief services is to ensure efficiency delivery of benefit payments to residents who have been displaced. This must be done while meeting strict regulatory requirements for timely payments, and maintaining processes that prevent fraud and improper payments. An agency has specific identity proofing requirements – functionality that is speedy and the ability to answer questions related to property ownership. In addition, in this scenario, the information needed at the beginning of the relationship, a simple “Who are you?” is different than the information required downstream, “Were benefits received?”

We can contrast the above scenario to the case of an agency providing retirement benefits. In this scenario, identity proofing is designed to improve customer service over repeat visits. Instead of requiring a user to repeat the same steps very time they log on, a “data minimization” process will be utilized so that the system only asks what it needs to know to facilitate the transaction. The first time an individual registers with an online retirement system, he/she will be asked to provide his/her name and ID number, and upon registering, will answer several knowledge-based authentication questions. During subsequent visits, interactions will be “fast-tracked” since the individual’s identity has already been proven. The system will perform an invisible check to confirm his/her identity using two-factor authentication, thus requiring less effort from the user while increasing efficiencies.

Regardless of the scenario, there are four technology fundamentals that should be encompassed by any comprehensive identity management solution: 

In the identity management process, data that is broad and deep is key to maximum results. The accuracy with which you can verify that individuals are who they say they are, and the percentage of the population that can be accurately verified, depends in part on the amount and variety of data your identity management system can access. Consider what you could do with data far beyond standard demographic information and what can be gleaned from a credit bureau check. Best-in-class solutions tap billions of public records that allow them to verify hundreds of millions of individuals and provide more interesting data better suited to knowledge-based authentication, such as the model of a car the consumer owned during a certain year. 

While data is necessary to create a robust identity management system, it is only meaningful if it can be leveraged to provide insights. It is essential to have the ability to link familial relationships to the identity of an individual that they have verified. In general, an identity proofing solution should be able to:

Locate data relevant to the identity being presented by your constituent;Match it with current constituent inputs, such as answers to knowledge-based questions, a voice or fingerprint, or a one-time pattern-based PIN;Normalize and fuse data to eliminate redundancies and improve consistency and efficiency for better real-time performance; andFilter and organization information into a multifaceted view that provides what you need to know for a particular transaction with confidence.

Analytics can provide further insight into data by detecting patterns of behavior, such as suspicious patterns of identity verification failure indicative of fraud or data integrity problems. Analytics can also be used to quantify identity risk by scoring the level of identity fraud risk associated with a particular transaction. The score will be given when your system’s rules and thresholds trigger an action; for benefits claims, these decisions would include things like accept, needs review, refuse, etc. This type of scoring provides an objective, consistent and reputable way of making complex decisions in a high volume scenario. By configuring rules within your identity management solutions, you enable it to make intelligent, dynamic decisions based on the information present and the level of risk you are willing to undertake.

Today’s business environment demands that organizations that engage in identity-reliant transactions ensure the security of the critical information that they collect. In addition to a high level of security, organizations also need an equal degree of flexibility to support a wide variety of organizational platforms and end-user devices. To accomplish this goal, it is best to choose an identity management solution that can provide services across various operational systems, channels and devices. They will also support many different ways for identities to be asserted, verified and authenticated, and can apply the appropriate degree of security based on the type of transaction. 

Due to the number of constituents they deal with on a daily basis, government agencies need to ensure that they are following best practices for identity proofing and using the most advanced solutions available to them. In addition, identities are often viewed at one point in time, but it is critical that agencies stay apprised of any changes to an individual’s status that may change his or her eligibility for benefits. Individuals will continue to try to perpetrate fraud and a robust identity proofing system is the best line of defense.

Clint Fuhrman is the National Director of Government Health Care Programs for LexisNexis Risk Solutions. Fuhrman joined LexisNexis in 2009 after serving as Deputy Secretary of the Florida Agency for Health Care Administration, where he helped direct agency strategy and operations in the areas of legislative affairs, communications, Medicaid policy, and health information technology.

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