Preventing and Recognizing Medicaid Fraud and Abuse

1. Preventing and Recognizing Medicaid Fraud and Abuse Medicaid Investigator 2, Christopher Bedell May 10, 2013 NEW YORK, NEW YORK

2. MISSION STATEMENT Our mission is to enhance the integrity of the New York State Medicaid program by preventing and detecting fraudulent, abusive, and wasteful practices within the Medicaid program and recovering improperly expended Medicaid funds while promoting high-quality patient care.

3. We Have A Statewide Presence Regional Offices: • Capital District • Western NY (2) • Central NY • Westchester • New York City (2) • Long Island

4. Facts About NY State Medicaid • Costs Tax Payers > $52 Billion • Nearly 5 Million Recipients • Over 60,000 Active Providers • Processes over 350 Million Claims Per Year • Medicaid is the Payer of Last Resort

5. OMIG Administration • Executive Office: James C. Cox, Medicaid Inspector General • Bureau of Agency Coordination & Communication • Bureau of Compliance • Bureau of Risk Management • Bureau of Quality Assurance

6. OMIG’S Organizational Structure • Office of Counsel • Office of Administration • Division of Medicaid Investigations • Division of Medicaid Audit • Division of Technology and Business Automation

7. Business Line Teams (BLTs) • Managed Care • Medical Services in an Educational Setting • Home and Community Care Services • Hospital and Outpatient Clinic Services • Mental Health, Chemical Dependence, and Developmental Disabilities Services • Pharmacy and Durable Medical Equipment • Physicians, Dentists and Laboratories • Residential Health Care Facilities • Transportation

8. Why Business Line Teams • Coordination between the divisions • Combines staff knowledgeable in their field • Improved efficiency • More thorough reviews and investigations • Reduced time to conclusion

9. Division Mission • Investigate fraud, waste and abuse in the Medicaid program • Deter improper behavior • Ensure that Medicaid recipients receive quality care • Foster cooperation with internal and external partners Deterrence Qualityof Care Cooperation PI* Fraud, Waste& Abuse * PI-Program Integrity

10. Division Structure • Provider and Undercover Investigations Unit • Recipient Fraud Unit • Pharmacy Investigations Unit • Administrative Remedies Unit • Enrollment and Reinstatement Unit • Recipient Restriction Unit

11. What is Medicaid Waste and Abuse? “Waste and abuse” are defined as practices that are inconsistent with professional standards of care; medical necessity; or sound fiscal, business, or medical practices; and that constitute an overutilization of Medicaid-covered services and result in an unnecessary cost to the Medicaid program

12. Types of Waste and Abuse • A provider ordering or performing unnecessary tests • Ordering unnecessary transportation • Ordering unnecessary durable medical equipment • Waste and abuse can lead to fraud

13. What is Provider Fraud? “Fraud means an intentional deception or misrepresentation made with the knowledge that the deception could result in an unauthorized benefit to the provider or another person and includes the acts prohibited by section 366-b of the Social Services Law.” – 18 NYCRR 515.1(b)(7)

14. Types of Medicaid Fraud • Services Not Rendered • Unnecessary Services • Unbundling • Kickbacks and Bribes • Upcoding

15. Services Not Rendered • Verify: Did you actually receive the service? Did it take place on the date noted on the EOB? • Is the provider (e.g., physician, therapist, dentist, etc.) actually the person you saw? • OMIG sends out explanation of benefits (EOBs) to recipients • Were you transported from point A to point B on the date noted?

16. Unnecessary Services Examples: • Restorative dental care for people who have no teeth • Monthly capitation fees for deceased managed care patients • Pre- and post-natal care for girls under the age of 10 or women over the age of 55 • Custom-fitted shoes for double amputees

17. Unbundling Supplies and/or Services Fraud schemes called “unbundling” involve instances in which a provider bills separately for the component parts of a product or service, resulting in a significantly larger payment to the provider. For instance, a durable medical equipment provider company was found to have billed for the component parts of a wheelchair separately, thus receiving four or five times more than if the wheelchair alone had been billed as a single item.

18. Kickbacks and Bribes • Providers cannot receive compensation in goods, money, or services in exchange for referring Medicaid recipients to other providers • It is illegal to pay a Medicaid recipient a fee to go to a medical practice to receive services • It is illegal to pay a “finder” to convince Medicaid recipients to choose a specific Medicaid provider

19. Upcoding You are medical billers and coders. You know that you cannot do things such as: • Bill for a full stroke when a Medicaid recipient (or anyone, for that matter) has a transient ischemic attack (TIA) (mini-stroke) • Bill for a Cesarean section when the patient had a vaginal delivery

20. What is Recipient Fraud? A recipient knowingly makes or causes to be made a false or misleading statement or representation for use in obtaining benefits from the medical assistance program

21. Types of Recipient Fraud • Eligibility • Drug diversion • Card lending • Selling drugs, supplies, or equipment obtained with Medicaid funds

22. OMIG Actions for Fraud, Waste and Abuse Providers: • Impose Sanction • Exclusion • Censure • Termination • Payment withholds • Referrals to the Attorney General’s Medicaid Fraud Control Unit and/or other law enforcement entities. Recipients: • Criminal charges/prosecution • Medicaid restriction/administrative remedies

23. Operating Principles • Majority of providers are honest • Criminals have infiltrated the health insurance system • Medicaid is part of the health insurance system • Bad providers prey on the most vulnerable • Everyone is a potential victim • Be a “HERO”: If you see something, say something

24. Thank You • Thanks for listening • Thanks for your diligence and achievements in serving those in your community • Thanks for working to improve program integrity

25. We Want to Hear from YOU • Our new, improved Web site: www.omig.ny.gov • Join our Listserv • Follow us on Twitter: @NYSOMIG • Dedicated e-mail: information@omig.ny.gov • More than 4,000 final audit reports • Audit protocols • And much, much more!

26. Contact Information Christopher Bedell Medicaid Investigator 2 New York State Office of the Medicaid Inspector General 250 Veterans Memorial Highway, Room 4A12 Hauppauge, NY 11788 631-952-6282 Christopher.Bedell@omig.ny.gov