Published: 2009-08-25 16:38:49
Author: Liv Osby | Greenville Online | August 1, 2009
South Carolina recovered $4.4 million more in Medicaid fraud and abuse collections from health-care providers in fiscal 2009 than it did the year before.
“Our recoveries from providers increased 145 percent from $2.9 million to $7.3 million, and overall recoveries increased 15 percent,” said Kathleen Snider, chief of the state Department of Health and Human Services' Bureau of Compliance and Performance Review.
The bureau looks for aberrant trends and inappropriate billing that could signify fraud, waste and abuse in the Medicaid program.
Billing spikes, ordering the same test for all patients, and billing for a procedure at least 50 percent more than other physicians in the same specialty are red flags, Snider said. Other tip-offs include obscure billing codes or codes that don't fit a diagnosis.
“There are probably hundreds of things we could look for,” she said.
Stepped-up recovery efforts are largely responsible for the huge increase in collections, Snider said. Two new staffers were hired last year, and the number of opened cases increased 58 percent, while the number of closed cases increased 42 percent, she said.
“It's a bad budget year for the state and it's been an agency focus to stretch our dollars,” she said. “Also, we're getting better at data analysis.”
And while there is no way to confirm whether the actual rate of fraud is on the uptick, the economy may be playing a role as the loss of coverage keeps privately insured patients out of doctors' offices, causing some providers to maybe pad their Medicaid bills.
“People in those circumstances might take some risks that they wouldn't normally,” said DHHS spokesman Jeff Stensland. “But we only have anecdotal evidence at best that that's the prime motivation behind some of this stuff.”
Not everyone who submits a questionable bill is trying to defraud the government, however. Often, there are honest mistakes resulting from a complicated system.Full story