Tag: Fraud

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Portman, Finance Committee Republicans raise concerns with improper Medicaid payments

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14 US Senators are asking CMS head Lasure to explain the plan to get a handle on the surging improper payment rate.

 
 

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

WASHINGTON, D.C. – U.S. Senator Rob Portman (R-OH), along with the other 13 Senate Finance Committee Republicans, sent a letter to the Centers for Medicare & Medicaid Services (CMS) highlighting concerns with the rising rate of improper payments in Medicaid, in anticipation of the next Medicaid Payment Error Rate Measurement (PERM) audit.

The November 2020 report found improper payments totaled over $86.5 billion — over 21 percent — mostly driven by eligibility errors. The letter further calls for enhanced program integrity measures and state-by-state analysis to ensure beneficiaries receive the services they are entitled to without wasting taxpayer dollars.

“One of the most common eligibility errors often occurs when failing to verify information provided by the applicant, including income. Failure to properly verify that applicants are eligible for the program, especially to this extent, harms the nation’s taxpayers and takes resources away from those who are eligible and who truly need the program,” said the senators.

“There is concern that the November 2020 improper payment rate estimate of 21.4 percent was unrealistically low because the eligibility reviews excluded one-third of states.

“Congress needs complete and updated information about the improper payment rate in Medicaid as well as the corresponding drivers of this problem. We understand that the essential work on the 2021 CMS improper payment report has concluded, and drafts of the report have been completed. While state and Federal responses to COVID-19 halted some payment and eligibility reviews in 2020, this work is too vital to remain paused when the consequences are so dire,” continued the senators.

Full text of the letter can be found below.

Dear Administrator Brooks-LaSure:

As some in Congress consider proposals to expand the Medicaid program by potentially half a trillion dollars over the next decade, it is vital that both Senators and Members of the House of Representatives have accurate information about how the program is using taxpayer resources. Every November, the Centers for Medicare and Medicaid Services (CMS) releases estimates of improper payment rates for programs within its jurisdiction. The November 2020 report showed that the Medicaid improper payment rate reached 21.4 percent, with total federal improper payments in the program amounting to $86.5 billion annually. Medicaid’s improper payment rate has significantly increased since the passage of the Affordable Care Act, which dramatically expanded Medicaid. In 2013, the year before the ACA’s Medicaid expansion took effect, the improper payment rate was just 5.8 percent.

According to last year’s report, eligibility errors are the major drivers of the increased Medicaid improper payment rate. According to CMS, “Eligibility errors are mostly due to insufficient documentation to affirmatively verify eligibility determinations or non-compliance with eligibility redetermination requirements.” One of the most common eligibility errors often occurs when failing to verify information provided by the applicant, including income. Failure to properly verify that applicants are eligible for the program, especially to this extent, harms the nation’s taxpayers and takes resources away from those who are eligible and who truly need the program.

There is concern that the November 2020 improper payment rate estimate of 21.4 percent was unrealistically low because the eligibility reviews excluded one-third of states. Since the Obama Administration cancelled eligibility audits from 2014-2017, this year’s forthcoming report will be the first complete assessment of all states since the expansion took effect. Given its more complete nature, the upcoming assessment has the potential to show that the improper payment rate in the program exceeds 25 percent, totaling above $100 billion annually.

Such a high improper payment rate demonstrates that the program requires a stalwart defense to ensure those that are eligible receive the care they need. This rate also raises questions of whether Congressional and regulatory actions have made Medicaid too complicated for the Federal government to properly oversee it, especially given the differing improper payment rates among states. Congress needs complete and updated information about the improper payment rate in Medicaid as well as the corresponding drivers of this problem. We understand that the essential work on the 2021 CMS improper payment report has concluded, and drafts of the report have been completed. While state and Federal responses to COVID-19 halted some payment and eligibility reviews in 2020, this work is too vital to remain paused when the consequences are so dire.

Given the importance of accurate data to inform ongoing policy discussions, by Monday, November 8, we ask that you provide:

The updated improper payment rate in Medicaid;
A breakdown of improper payment rates by state; and
The corresponding estimated total of improper payments from insufficient verification or non-compliance with eligibility requirements.

When asked about this at a June hearing in front of the Senate Finance Committee, Secretary Becerra committed to making available such data. We also request a briefing with Committee Members’ staff, so that Congress can ask informed questions on this important matter.

 
 

Clipped from: https://highlandcountypress.com/Content/In-The-News/In-The-News/Article/Portman-Finance-Committee-Republicans-raise-concerns-with-improper-Medicaid-payments/2/20/73497

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Mass. Medicaid fraud case settled for record $25 million, AG’s office says

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The provider was using unlicensed workers at its mental health facilities.

 
 

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

A private equity firm and two former top executives at a Massachusetts chain of mental health centers have agreed to pay $25 million in a whistle-blower lawsuit brought by the attorney general’s office, marking the largest MassHealth fraud settlement in state history, officials said Thursday.

South Bay Community Services (formerly known as South Bay Mental Health) has operated facilities in more than a dozen Massachusetts communities, including Boston, Brockton, Fall River, Lowell, Pittsfield, and Worcester, the office of Attorney General Maura Healey said in a statement.

South Bay has provided services to some 30,000 people receiving benefits through MassHealth, the state’s Medicaid program for low-income residents. But many of the staff at its mental health facilities were unqualified, unlicensed, and lacked proper supervision, violating MassHealth regulations, according to the AG’s office.

 
 

Clipped from: https://www.bostonglobe.com/2021/10/14/metro/mass-medicaid-fraud-case-settled-record-25-million-ags-office-says/

 
 

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NY- DiNapoli: Medicaid Billing Errors Cost State More Than $1.5 Billion

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The latest report shows the state pays claims without required provider ids.

 
 

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

Patients Potentially Put at Risk by Dept. of Health’s Failure to Ensure Health Care Providers Were Properly Qualified

The state Department of Health (DOH) allowed more than $1.5 billion in improper Medicaid payments over the course of several years due to errors in its billing system and may have exposed patients to unqualified and uncredentialed health care providers, according to three reports released today by State Comptroller Thomas P. DiNapoli.

“Troubling errors like the ones routinely identified by my auditors are extremely costly. They can also put patients at risk,” DiNapoli said. “By not fixing problems with the Department of Health’s eMedNY system and other issues, hundreds of millions of dollars more in taxpayer dollars could be misspent and unqualified providers could continue to treat Medicaid patients. The department must act on our recommendations and address these shortfalls, so Medicaid recipients receive the level of care they deserve, and taxpayers’ dollars are spent effectively.”

For the state fiscal year that ended March 31, 2020, New York’s Medicaid program had approximately 7.3 million recipients and Medicaid claim costs totaled $69.8 billion.

The Affordable Care Act and federal regulations mandate that state Medicaid agencies require all ordering and referring physicians and other professionals providing services through the Medicaid fee-for-service program to be enrolled as participating providers and their National Provider Identifiers (NPIs) to be included on Medicaid claims. This screening and provider enrollment process improves the efficiency of the health care system and helps to reduce fraud and abuse. It also helps to ensure the quality of services and protects public health by validating that providers have the appropriate credentials to provide services and are not prohibited from participating in the Medicaid program by the federal government.

In the first report, DiNapoli’s auditors found that a significant number of claims were paid even though they did not have a proper NPI to ensure the ordering, prescribing, referring, or attending provider was properly qualified or credentialed, creating a risk for patients. Processing weaknesses in eMedNY, the Medicaid claims processing and payment system, allowed $1.5 billion in payments for Medicaid clinic and professional claims without an appropriate NPI.

For example, some claims contained NPIs of providers who were not enrolled in Medicaid, while other claims did not contain an NPI at all.

Auditors also found $57.3 million in payments for pharmacy claims that did not contain an appropriate prescriber NPI and $19.4 million in payments for claims that contained an NPI but, according to regulations, should not be included on Medicaid claims or that should be further reviewed by DOH due to past misconduct.

Auditors recommended DOH:

  • Review the Medicaid payments for claims not containing an appropriate NPI identified by the audit and determine an appropriate course of action.
  • Enhance system controls to prevent improper Medicaid payments for claims not containing an appropriate NPI.

The department’s full response to the findings and recommendations is included in the audit.

A second report found that from Jan. 1, 2015 through Dec. 31, 2019, claims totaling $28.5 million were paid for Medicaid recipients who were reported as discharged from a hospital, but then admitted to a different hospital less than 24 hours later. These claims raise the possibility that the first hospital wrongly recorded a patient’s transfer as a discharge, which is a red flag that the claims are at a high risk of overpayment.

In fact, auditors found nearly half of the claims that they sampled (15 of 31) were incorrectly coded as discharges in the eMedNY system. The result of those errors was overpayment of $252,107, or 55% of the total value of the 31 sampled claims. This high error rate raised concerns about the extent of overpayment in the $28 million of high-risk claims. Auditors also found that DOH has no process to identify and recover such improper Medicaid payments.

Auditors recommended DOH:

  • Develop a process to identify and recover Medicaid overpayments for fee-for-service inpatient claims that have a high risk of incorrect patient status codes such as those identified by the audit.
  • Review the $252,107 in overpayments and recover as appropriate.
  • Review the remaining 2,017 high-risk claims totaling $28 million and recover overpayments as appropriate. Ensure prompt attention is paid to those providers that received the highest amounts of payments.

In their response, department officials agreed with the audit recommendations and said actions will and have been taken. Their response is included in the report.

An audit released in July 2019 identified more than $102.1 million in improper managed care premium payments on behalf of 65,961 recipients who had multiple identification numbers in the eMedNY system. In a follow-up report released today, auditors found DOH made progress addressing the problems identified in the initial audit report and the Office of the Medicaid Inspector General recovered $50.8 million of the $102.1 million identified. Another $51.3 million still needs to be recovered.

Since the 2019 audit, auditors identified another $14.3 million in managed care premium payments for 14,293 potentially inappropriate identification numbers for the period July 1, 2018, to Aug. 31, 2020. According to department officials, many of these cases have been resolved or are currently being reviewed.

Audits

Improper Medicaid Payments for Claims Not in Compliance With Ordering, Prescribing, Referring, and Attending Requirements (2019-S-2)

Improper Medicaid Payments for Misclassified Patient Discharges (2020-S-8)

Improper Managed Care Premium Payments for Recipients With Duplicate Client Identification Numbers (2020-F-22)

 
 

Clipped from: https://www.perugazette.com/2021/08/24/dinapoli-medicaid-billing-errors-cost-state-more-than-1-5-billion/

 
 

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KANSAS- Audit reveals KDHE mistakenly paid $1.3 million to Medicaid contractors for care of dead people

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A new audit finds various issues with payment integrity in KS Medicaid, some of which have been addressed, some have not.

 
 

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

Review shows agency caught $19.2 million in overpayments over 2-year period

 
 

A state inspector general discovered the Kansas Department of Health and Environment didn’t detect overpayment of $1.3 million to private companies contracted to deliver services under Medicaid. (Illustration by Kansas Reflector)

TOPEKA — An expansive audit of Kansas Department of Health and Environment’s payments to companies contracted to deliver services under the state’s Medicaid program found $1.3 million in inappropriate compensation for care of people who had actually died.

Steven Anderson, the state’s Medicaid inspector general, said the examination found 25 instances from 2015 to 2020 in which KDHE cut checks for beneficiaries who were deceased. When the report was issued last week, KDHE hadn’t yet recouped the cash from the managed-care companies handling KanCare. Approximately 360,000 Kansans are Medicaid recipients.

In addition, analysis by Anderson of the period from July 2019 and July 2021 showed KDHE had identified $19.2 million improperly paid to the contractors that was subsequently recovered by docking future payments. The mistakes caught by KDHE involved 632 cases in which the state continued making payments after a death. In 56 of those cases, the inspector general’s report said, inappropriate payments had continued for five or more years after the beneficiaries’ demise.

Anderson’s office reviewed the length of time overpaid funds were in possession of MCOs and determined the miscue was equivalent to giving those for-profit companies a $1.5 million cash loan.

The report from the inspector general recommended KDHE “review quality control measures and staff training protocols to ensure they are sufficient to confirm staff members know how to effectively and efficiently identify and process cases involving death of a beneficiaries.”

Apparently many of the mistakes occurred when the company Maximus was under contract from 2016 to 2020 to operate the state’s Medicaid clearinghouse for processing claims. KDHE should consider feasibility of taking legal action against Maximus to recover funds, Anderson’s report said.

In Kansas, KDHE is responsible for administering Medicaid, also known as KanCare. KDHE contracts with three companies to coordinate health care for individuals enrolled in KanCare. The Medicaid inspector general, housed in the attorney general’s office, is responsible for independent and ongoing reviews of the program.

“We have worked hard, in cooperation with the Legislature, to revitalize the office of Medicaid inspector general into a professional, independent reviewer that can promote efficiency in the Medicaid program,” said Attorney General Derek Schmidt. “These audits are products of that important work to reduce fraud and identify cost savings within the Kansas Medicaid, MediKan and State Children’s Health Insurance programs.”

 
 

MediKan benefit woes

The inspector general also released a July 30 report outlining challenges facing Kansans interested in reporting Medicaid fraud and recommended ways of improving access to the proper points of contact.

In a third report, also released on July 30, Anderson said 912 MediKan beneficiaries who exceeded the 12-month lifetime eligibility limit between January 2018 and April 2021. Providing benefits beyond the maximum period resulted in the state paying $1.6 million for medical claims for adults 18 to 64 years of age who were  ineligible for the program, the audit said. MediKan is a state-funded initiative providing medical services for people with physical or mental disabilities who wouldn’t qualify for Medicaid.

Kristi Zears, spokeswoman for KDHE, said 457 of the ineligible recipients of MediKan benefits were discontinued before release of the inspector general’s audit. The other 455 improper recipients had been discontinued by July 29, she said.

“We appreciate the work of the Medicaid inspector general and welcome the opportunity to further improve state medical assistance programs,” said Zears, who indicated KDHE’s reporting system would guarantee timely discontinuation of ineligible people.

The inspector general, who is required by state law to report on fraud, waste, abuse and illegal contact, presented the information to Schmidt, KDHE secretary Lee Norman, KDHE Medicaid director Sarah Fertig and the House and Senate members on the KanCare oversight committee. The joint legislative oversight committee’s meeting Tuesday was called off with a tentative plan to convene lawmakers during September.

Under KanCare, the managed-care companies receive a monthly payment from the state for each eligible beneficiary enrolled with that company regardless of whether the person incurred medical costs that month.

Sunflower State Health Plan and United Healthcare Community Plan of Kansas have worked in the privatized Medicaid system since implemented in 2013 during the administration of Gov. Sam Brownback. Amerigroup’s contract was allowed to expire by KDHE in 2018 and that troubled company was replaced by Aetna Better Health of Kansas.

 
 

Clipped from: https://kansasreflector.com/2021/08/11/audit-reveals-kdhe-mistakenly-paid-1-3-million-to-medicaid-contractors-for-care-of-dead-people/

 
 

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MS may be paying out fraudulent Medicaid benefits

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A new audit in MS shows members are getting enrolled even when they are ineligible due to higher incomes.

 
 

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

As part of its Single Audit Report for the 2020 fiscal year, the Mississippi auditor’s office sampled 180 Medicaid beneficiaries and found that nine of them were ineligible due to the high income reported on their state tax returns.

On average, those nine reported income levels $10,727 above the threshold for Medicaid enrollment.

In addition to the nine individuals flagged in the sample, two people who own multi-million dollar homes and declared high incomes on their tax returns, despite receiving Medicaid benefits, had already been flagged as potential fraud cases to investigate. 

Under current state law, the Mississippi Division of Medicaid does not have the legal authority to obtain state income tax returns to compare them with the income declared by a person applying for Medicaid benefits. State Auditor Shad White is now calling on Gov. Tate Reeves and the Legislature to grant this authority so that potential fraud can be prevented on the front end. 

“I stand ready to work with Medicaid’s leadership to argue to lawmakers that they should have this tool in their toolbox,” White said in a press release. “It could stop ineligible applicants from being put on the program in the first place. We know this tool would be useful because Medicaid’s internal policies state they should ask an applicant for their return, but without the authority to get the return and a requirement to use it, the state is potentially handing out millions to ineligible people.”

In a statement, the Mississippi Division of Medicaid (DOM) said it does not agree that the use of state tax returns would help root out fraud, as the tax information used by the auditor’s office in this case is from more than a year before the person applied for Medicaid. DOM is required to base eligibility on current income and noted that “financial information that far out of date may not accurately reflect the current circumstances of applicants.”

In June 2019, the most recent month for which figures are available, 673,247 Mississippians were enrolled in Medicaid.

Clipped from: https://mississippitoday.org/2021/08/02/mississippi-fraudulent-medicaid-benefits/

  

 

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Controller finds overpayments, money spent on yoga in Philly’s administration of Medicaid funding

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The latest audit of Philadelphia Medicaid payments shows egregious issues that the mayor is dismissing.

 
 

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

The controller’s report flagged overpayments, plus money spent on fitness and yoga instructors.

 
 

City Controller Rebecca Rhynhart speaking at a news conference last year.Read moreMONICA HERNDON / Staff Photographer

The Philadelphia agencies overseeing distribution of $1 billion in Medicaid funding for mental health and drug and alcohol services have overpaid providers and lacked proper documentation and oversight, according to an audit by the city controller released Thursday.

Controller Rebecca Rhynhart‘s office examined the administration of Medicaid funds in fiscal year 2017 and found $10 million in payments for services that were not actually provided, $4 million in temporary advances to providers that were not paid back, and money spent on employee perks such as fitness and yoga instructors.

“It is so important that this [money] is used well so that the people of our city can deal with addiction issues and trauma issues,” Rhynhart said in an interview.

The city’s Department of Behavioral Health and Intellectual disAbility Services (DBHIDS) distributes about $1 billion annually through the HealthChoices program and contracts with Community Behavioral Health (CBH), a nonprofit that acts as a quasi-governmental agency and administers funds to health-care providers. Money for HealthChoices comes from state Medicaid funding and does not include money from the city’s coffers. But Philadelphia, like other counties in Pennsylvania, is responsible for distributing and administering the Medicaid funding.

Mayor Jim Kenney, who often trades barbs with Rhynhart over her audits and reports, criticized the audit in a statement Thursday and said the agencies’ work has “established Philadelphia as an internationally recognized model for managed care.”

“There is little value to the public in a single audit looking at data that is nearly five years old – especially when CBH has successfully completed multiple rigorous accreditation and oversight reviews from national and state experts since that time,” Kenney said.

The agencies said in a news release that much of the “narrow set of recommendations” had already been implemented through changes in policies and leadership since 2017.

Rhynhart, however, said she still recommends that Community Behavioral Health implement stronger internal controls to monitor health-care providers and compliance with city policies.

Community Behavioral Health runs a recovery center program through which 13 different providers offer services to Medicaid patients in Philadelphia. The audit found that the providers were paid $33 million in fiscal year 2017 based on estimated services but did not reach full capacity and therefore were overpaid by $10.4 million.

Rhynhart’s report asserted that while auditors reviewed only one year of payments, “it is likely that CBH has paid providers millions of dollars annually for services not rendered to actual patients since the program’s inception.”

» READ MORE: Lawmakers renew call for stronger addiction treatment oversight as two Pa. providers charged

DBHIDS acknowledged in its response that recovery center providers had been receiving flat-funding while their numbers of patients decreased. The department said that issue was fixed in 2018 with a new payment system.

The controller’s office found instances of Community Behavioral Health giving temporary advances to providers, for which two providers defaulted on about $4 million in repayments during fiscal year 2017.

The audit also found that the city reimbursed Community Behavioral Health for more than $200,000 in “questionable” operating costs. That amount included $149,000 to celebrate the organization’s 20th anniversary with a day off for employees, buffet meals costing $11,000, promotional gifts, and a photo booth, as well as $54,000 for fitness and health programs for employees that included in-house massages, yoga, personal training sessions, healthy snacks, and FitBits.

The audit said that the city’s contract with Community Behavioral Health does not define ineligible costs, and the city does not review submitted expenses to determine whether they are appropriate. Rhynhart recommended improving oversight and implementing a formal review process.

The city’s response maintained that the 20th anniversary and employee wellness costs “are well within the purview of reasonable administrative expenses of a nonprofit organization.”

Rhynhart disagreed in a letter to DBHIDS Commissioner Jill Bowen. “I would like to emphasize that they are not necessary for the administration of the HealthChoices Program and come at the expense of Philadelphians in need of the essential services CBH provides,” she wrote.

While issues with overpayments or eligible reimbursements for an anniversary celebration do not affect the city’s operating budget, the Medicaid programs are funded with federal taxpayer money. And Rhynhart said that inappropriate spending uses up money that could be spent on helping needy Philadelphians with mental health and addiction.

“There’s this multitiered structure that exists, but despite that structure there really is a lack of oversight and accountability in many of our findings,” Rhynhart said.

Bowen said in a statement Thursday that the city “will continue to evolve and improve our services.”

The controller’s office also found issues with documentation, based on sampling 284 transactions and finding 149 instances of noncompliance with the documentation that health-care providers must give to Community Behavioral Health.

“That sounds very technical,” she said, “but it’s also the basic requirement and building blocks for services.”

 
 

Clipped from: https://www.inquirer.com/news/controller-rhynhart-medicaid-philadelphia-behavioral-health-20210729.html

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Libertarian group sues government over information on $143 billion in improper Medicaid payments

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CMS has been sued for not providing information about what its doing to reduce improper payments in accordance with FOIA timelines.

 
 

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

 
 

The libertarian organization Americans for Prosperity Foundation is suing the Centers for Medicare and Medicaid Services to find out what it is doing about $143 billion in improper payments made by Medicaid.

The complaint asks for records on CMS’s efforts to recover improper Medicaid payments and for data showing improper payment rates by states. According to CMS, improper Medicaid payments totaled $143 billion in 2019 and 2020, rising from 14.9% of all payments in 2019 to 21.4% in 2020. Medicaid is a joint federal-state healthcare program for the poor.

“Failing to recover $143 billion in improper Medicaid payments is an affront to hardworking American taxpayers and a threat to Medicaid’s long-term fiscal stability,” said Dean Clancy, a senior health fellow at Americans for Prosperity Foundation. “More transparency and accountability is needed to ensure that CMS manages Medicaid responsibly.”

The $143 billion in improper payments is about 11% of the roughly $1.3 trillion spent by Medicaid from 2019 to 2020. By contrast, Medicare, the federal healthcare program for seniors and the disabled, had about $55 billion in improper payments in 2019 and 2020. Additionally, Medicare’s improper payments declined from almost $29 billion in 2019 to just under $26 billion in 2020.

Federal law requires CMS to recover any improper payments over the amount of 3%.

SENATE DEMOCRATS PLAN END RUN AROUND STATE THAT HAVEN’T EXPANDED MEDICAID UNDER OBAMACARE

Americans for Prosperity Foundation requested CMS supply the information on improper payments under a Freedom of Information Act request it filed on May 5, 2021. Under federal law, an agency has 20 days to respond to a FOIA request or 30 days under unusual circumstances. When CMS did not comply, Americans for Prosperity Foundation filed suit in federal court.

An improper payment occurs when a recipient receives an incorrect amount of funds or uses the funds in an improper way or when the recipient is ineligible to receive the funds in the first place. Medicaid enrollees cannot receive benefits when they earn more income than is allowed under the program or when they fail to meet residency requirements. The Americans for Prosperity Foundation complaint notes that state governments often do not ensure compliance with federal Medicaid requirements.

CMS did not immediately respond to a request for comment.

CLICK HERE TO READ MORE FROM THE WASHINGTON EXAMINER

Democrats in Congress are trying to expand Medicaid. Georgia Sens. Raphael Warnock and Jon Ossoff and Wisconsin Sen. Tammy Baldwin are trying to establish a Medicaid-like coverage plan run by the federal government. It would cover people who live in the 12 states that have not yet expanded Medicaid under Obamacare. The federal government would fully fund the plan. States would not have to provide matching funds.

 
 

Clipped from: https://www.washingtonexaminer.com/news/group-files-suit-over-medicaid-improper-payments

 
 

 
 

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Great Circle, accused of overbilling Medicaid by nearly $2 million, settles case for less than $10,000

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A MO behavioral health provider has successfully fought back $2M of services-not-provided allegations.

 
 

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

 

 
 

Jesse Bogan

WEBSTER GROVES — A highly publicized case that accused Great Circle of overbilling Medicaid for a lot of behavioral health services that may not have happened has taken an abrupt turn in the nonprofit’s favor. Instead of being on the hook for nearly $2 million, Great Circle must pay just $9,253.18, according to a recent settlement agreement that admits no wrongdoing.

“Great Circle’s policy is one of transparency — and that includes full cooperation with all reviews, audits and investigations,” Paula Fleming, Great Circle’s chief executive, said Tuesday in a news release. “We took this issue very seriously and, through collaboration, we were able to reach a conclusion both favorable to Great Circle and acceptable to the state.”

A January letter from the Missouri Medicaid Audit and Compliance Unit to Great Circle said $1,992,157 in “improper billing” had been identified. Great Circle, which has state contracts to provide an array of services for troubled youths across Missouri, many of whom have autism or are in foster care, appealed the audit findings to the Administrative Hearing Commission on Feb. 18, two weeks after a federal raid of its headquarters here.

According to records on file in the appeal, the audit was prompted by “data analysis that suggests possible over-utilization of therapy services.”

“The alleged overpayments are not based on any finding that the services for which (Great Circle) was paid were not actually provided, or any finding that they were not medically necessary,” Elizabeth Blackwell, an attorney for the nonprofit, argued in the original petition.

 
 

Clipped from: https://www.stltoday.com/news/local/metro/great-circle-accused-of-overbilling-medicaid-by-nearly-2-million-settles-case-for-less-than/article_9b1d75a8-550c-5fd8-aab8-2c4db3cf9e14.html

 
 

 
 

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Missouri company, Healthy Home & Family, Inc, settles Medicaid fraud case for $300,000

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A home care agency stole $300k in taxpayer dollars using falsified billing records.

 
 

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

 
 

Missouri Attorney General Eric Schmitt announced that on April 27, 2021, Healthy Home & Family, Inc., an in-home health care provider, and its owners, Belinda Bivens and Mary Stockson, have entered into a civil settlement agreement totaling $302,127 in restitution and penalties, with his office for submitting 114 false claims to Missouri Medicaid (MO HealthNet).

“Identifying Medicaid fraud and taking legal action to prevent it are two integral duties of my Office’s Medicaid Fraud Control Unit,” said Attorney General Schmitt. “Gaming the Medicaid system for personal gain is against the law and preys on our state’s most vulnerable, and my Office will not hesitate to take action. In this case, my Office recovered over $300,000 in restitution and penalties, a great result for MO HealthNet and Missouri.”

The Attorney General’s Medicaid Fraud Control Unit (MFCU) discovered Healthy Home overbilled MO HealthNet for services that were to be provided in Medicaid recipients’ homes. The MFCU also found that Healthy Home attempted to cover up their fraudulent scheme by purposely altering records.

In the settlement agreement, Healthy Home, located in Farmington, Missouri, admitted that between October 9, 2018, and June 14, 2019, they submitted false claims to MO HealthNet seeking payment for more hours than their attendants actually provided care to recipients and that they later altered attendants’ timesheets to conceal the fraud.

In addition to the restitution and penalties, Healthy Home agreed to enhanced monitoring and oversight. The Medicaid provider is required to submit a corrective action plan to the Missouri Department of Social Services’ Medicaid Audit and Compliance Unit and be subject to a close-ended one-year provider enrollment agreement.

This case was prosecuted by Assistant Attorneys General Travis Turner and Sarah Schappe and investigated by MFCU Investigator Taylor Walls.

The Missouri MFCU receives 75 percent of its funding from the U.S. Department of Health and Human Services under a grant award totaling $2,818,808 for the federal fiscal year 2021. The remaining 25 percent, totaling $939,601, is funded by the State of Missouri.

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Clipped from: https://www.kttn.com/missouri-company-healthy-home-family-inc-settles-medicaid-fraud-case-for-300000/

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CMS Failed to Flag Medicare Fee-for-Service Healthcare Fraud, Waste

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CMS did not use a method recommended by OIG for preventing payments to providers known to have high payment error rates.

 
 

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

From 2014 to 2017, CMS had an improper payment rate of 60.7 percent, accounting for $3.5 million in healthcare fraud, waste, and abuse.

January 28, 2021 – The Centers for Medicare & Medicaid Services (CMS) and its contractors did not use Comprehensive Error Rate Testing (CERT) data to identify healthcare fraud or waste, according to a new Office of Inspector General (OIG) audit.

Data from the CERT program measures improper Medicare fee-for-service payments to providers. Previous OIG reports have recommended that CMS harness CERT data to determine error-prone providers and correct processes that contribute to these errors.

However, after reviewing CERT data from 2014 to 2017, the agency determined that CMS did not use the data to identify error-prone providers.

Of the $5.8 million reviewed by CERT, $3.5 million was an incorrect payment, making for an improper payment rate of 60.7 percent. OIG tracked these incorrect payments to 100 error-prone providers.

These providers had an error rate higher than 25 percent in each of the four CERT years analyzed and a total error amount of at least $2,500.

During the same time period, Medicare made $19.1 billion in FFS payments to those 100 error-prone providers.

In the audit, OIG recommended that CMS review this list of 100 error-prone providers and take action to reduce incorrect payments. This could include processes such as prior authorization, prepayment reviews, and postpayment reviews for these providers.

Like previous reports, OIG called on CMS to use annual CERT data to identify specific providers that have an increased risk of receiving improper payments. Additionally, OIG suggested CMS apply additional program integrity tools to monitor these providers.

CMS did not agree with OIG’s recommendations in written comments to the draft report.

“CMS disagreed with our methodology for identifying error-prone providers and suppliers. Additionally, CMS stated that it previously attempted to use CERT data to identify error-prone providers and suppliers but found that CERT data was ineffective for this purpose and discontinued the practice,” the agency said.

OIG reviewed CMS’s comments and maintained that its recommendations are valid in lowering improper payment rates.

“We maintain that CMS can improve its ability to detect these types of providers by using the provider-level CERT data along with its existing oversight efforts,” the OIG audit explained.

In recent years, aggressive corrective actions to reduce Medicare FFS improper payments in particular have led to less healthcare fraud, waste, and abuse. Data released in November of last year revealed that the Medicare FFS improper payment rate declined to 6.27 percent in fiscal year (FY) 2020 from 7.25 percent in FY 2019 leading to $15 billion in savings.

2020 was the fourth consecutive year that the Medicare FFS improper payment rate fell below 10 percent, CMS reported.

“President Trump made a clear commitment to protect Medicare for our seniors, and to do that we must ensure that fraud and abuse doesn’t rob the program of precious resources,” CMS Administrator Seema Verma said at the time of the data’s release.

“From the beginning this administration has doubled down on our commitment to protect taxpayer dollars and this year’s continued reduction in Medicare improper payments is a direct result of those actions,” Verma continued.

However, based on OIG’s CERT data review that revealed over $19 billion in improper Medicare FFS payments to error-prone providers, CMS has room for improvement in terms of reducing fraud, waste, and abuse in the healthcare industry.

Clipped from: https://revcycleintelligence.com/news/cms-failed-to-flag-medicare-fee-for-service-healthcare-fraud-waste