Medicaid Fraud Losses Exceed Recovery by Millions in North Carolina

Medicaid fraud is at a crisis level of losses that exceed recovery in North Carolina. The Final Report to the Joint legislative Program Evaluation Oversight Committee, Report Number 2016-10 dated November 14, 2016, entitled: “Medicaid Program Integrity Section is Not Cost-Effectively Identifying and Preventing Fraud, Waste, and Abuse, reveals that costs to discover fraudulent claims hovered at $13.8 million.

Of that amount $5.2 million funded the Program Integrity staff and $8.6 million was paid to private contractors.

One of the reasons stated for the large expense to recovery ratio is the absence of a formal risk assessment process.

Amendments to the law, according to the report, include the adoption of a uniform methodology to identify and measure Medicaid eligibility and medical service claim errors, provide incentives that reward accuracy in eligibility, discover methods to increase recoup amounts and continue investigation/prosecution, develop and implement a Progressive Corrective Action process for tighter controls and construct reporting systems and procedures that provide concrete plans, actions and accountability.

“Scamming the health care system is endemic and drives up the cost of health care, eliminating fraud would be a giant step toward achieving Congress’ goal of affordability,” says John Benson, Verisys CEO. “It would require massive changes to existing flawed systems and challenging the CMS contractors whose very expensive systems just add more cost by engaging in the pay and chase game. We need to have an honest discussion about prevention and it starts with a solid gatekeeping and monitoring strategy, something that Verisys delivers in the commercial sector today. The government needs to stop spending money on magic bullets and start applying common sense solutions.”

“ACA has yet to deliver on the promise of paying for itself by preventing fraud,” says Benson, “and whatever replaces it is not going to eliminate continuing huge losses attributed to system flaws that allow for massive dollars lost to waste, abuse and fraud in the health care system. Verisys has the knowledge and experience to deliver solutions that prevent fraud and limit its impact by implementing gatekeeping and monitoring solutions as opposed to pay and chase.”

http://www.ncga.state.nc.us/DocumentSites/committees/JLPEOC/Minutes%20and%20Handouts/2016/11-15-16/Program%20Integrity%20Report.pdf
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