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Editorial: Fraud unit needs to catch up, prepare for bigger workload

Oct. 01, 2013 @ 12:00 AM

The state agency responsible for ferreting out Medicaid fraud has improved its performance over the last several years, legislative auditors say, but it can still do a better job.

With the possibility that nearly 100,000 West Virginians will be added to the Medicaid program because of federal health care reform, the agency had better gear up to improve its performance more.

An audit report released last week found that the West Virginia Medicaid Fraud Control unit had a backlog of 171 cases involving overpayments or improper payments to Medicaid providers. Most disturbing was that 23 of the cases involve complaints as far back as 2009 or earlier. It’s difficult to fathom how cases can linger for four or more years, but that’s where it stands now. "As you can see, suspicious billings from providers can remain uninvestigated for years," legislative research analyst Derek Hippler told the joint committees on Government Operations and Government Organization on Wednesday, according to a report in The Charleston Gazette.

The new report follows an audit on the same subject six years ago. It’s encouraging to learn that the new report credits the fraud control unit and its associated agencies with making some strides since 2007. For example, the new report cites better communication between the Bureau of Medical Services and the fraud control unit. The fraud unit also began conducting background checks of providers considered to pose higher risks of problems, such as durable medical equipment companies, transportation services and home-health agencies.

One recommendation from six years ago remains cast aside, however. That involved conducting pre-payment reviews of claims submitted by providers who previously have been investigated for billing fraud. Nancy Adkins, the Bureau of Medical Services’ Medicaid commissioner, said adding the resources to conduct those types of pre-payment checks might cost more than the amount of money recovered. However, considering that the fraud unit has an operating budget of about $1 million yet recovered about $20 million in overpayments last year, the agency may want to invest more in checking out previous offenders before paying their claims.

The good news from Adkins is that the fraud unit is hiring more staff, plus it plans to implement data-analysis technology early next year to spot irregular billing patterns and claims. With those additional resources, the agency should work hard to eliminate the backlog of cases – especially the older ones – and brace itself for a likely heavier workload once the Medicaid coverage is expanded to more state residents.

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