Transcript Medicaid Fraud 101 - Central Ohio HFMA Chapter

Medicaid Fraud 101
Healthcare Financial Management Association
Ohio Chapter – Spring Conference
March 19, 2015
Lloyd Early - Special Agent-In-Charge
Ohio Attorney General’s Office
Medicaid Fraud Control Unit
MFCU
• Title XIX of the Social Security Act
• 1977 Anti-Fraud and Abuse
Amendment
• 42 U.S.C. 1396
• Ticket to Work and Work Incentive
Improvement Act of 1999
• R.C. 109.85
$ 450,000,000,000
$ 580,000,000,000
$ 1,800,000,000,000
$ 2,800,000,000,000
$ 70,000,000,000
“Slick” Willie Sutton
What is fraud?
• It is a theft…
• …by deception
• It is an intentional (or at least
knowing) misrepresentation
• It is, by design, difficult to detect
R.C. 2913.40 Medicaid Fraud
“No person shall knowingly
make or cause to be made a
false or misleading statement or
representation for use in
obtaining reimbursement from
the medical assistance
program.”
Provider Fraud Schemes
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Billing for services not rendered
Billing for “phantom patients”
Double billing
Up-coding
Unbundling
Billing for medically unnecessary
services
• Billing for non-covered goods/services
• Kickbacks
Emerging Fraud Trends
• Prescription drug diversion
– Pill mills
– Long term care facility diversion
• Falsification of criminal background
checks
• Ambulette (wheelchair van) services
• Home Health Services
MFCU Home Health Complaints
400
350
300
Complaints
250
200
150
100
50
0
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
MFCU Secrets
• Collaboration and cooperation
• Peer comparisons and data mining
algorithms
• Bank/credit card records
• Covert physical surveillance
• Covert video surveillance
• Handwriting analysis
• Forensic chemistry
Ohio Attorney General Mike DeWine
Health Care Fraud Section
Medicaid Fraud Control Unit
150 E. Gay Street, 17th Fl.
Columbus, OH 43215
(614) 466-0722
Lloyd Early, Special Agent-In-Charge: (614) 466-0786
[email protected]
On-line fraud reporting form:
http://ohioattorneygeneral.gov/files/Forms/Forms-for-Seniors/Report-MedicaidFraud.aspx
On-line abuse/neglect reporting form:
http://www.ohioattorneygeneral.gov/About-AG/Service-Divisions/Health-CareFraud/Report-Patient-Abuse-or-Neglect
Ohio Attorney General’s Help Center: (800) 282-0515