The Register-Herald, Beckley, West Virginia

September 27, 2013

Audit faults Medicaid fraud efforts

Associated Press

— Legislative auditors say West Virginia’s efforts to reduce Medicaid fraud and overpayments are lacking, citing a backlog of 171 cases involving billings from health care providers.

The backlog includes 23 complaints that are at least four years old, according to a legislative audit. The audit was released Wednesday during legislative interim meetings, the Charleston Gazette  reported.

“As you can see, suspicious billings from providers can remain uninvestigated for years,” legislative research analyst Derek Hippler told the joint committee on Government Operations and Government Organization.

Nancy Adkins, Medicaid commissioner for the state’s Bureau of Medical Services, told lawmakers that additional staff is being hired by the Medicaid Fraud Control Unit. New data-analysis technology expected to be online early next year will flag unusual billing patterns and claims.

“We are looking at technology to help us work smarter,” she said.

Adkins said the fraud unit recovered nearly $20 million in overpayments in 2012. The unit’s annual operating budget is about $1 million.

The audit said that the fraud unit was in compliance or partial compliance with many recommendations made by an earlier audit in 2007. The recommendations included improving communications between the Bureau of Medical Services and the fraud unit, and conducting background checks of so-called high-risk providers, including durable medical equipment companies, transportation services and home-health agencies.

But the fraud unit has not complied with a recommendation to conduct pre-payment reviews of claims submitted by providers who previously have been investigated for billing fraud.

Adkins said pre-payment reviews are costly and only a handful of states conduct them.

“It may cost us more than we would actually recoup,” she said.

Another concern is that pre-payment reviews would cause providers to stop accepting Medicaid patients, she said.

“We do post-payment review,” she said. “We pay it and, if we think it’s inappropriate, we go after it.”