Trends in Combatting Fraud,
Waste, and Abuse in Medicaid
Shelly Marie Martin
Deputy Director, Medicaid Fraud Control Unit
Susan Steinberg
Assistant Inspector General, Department of Health and Mental Hygiene
Agencies Involved in the Fight
• Federal
– HHS‐OIG
– DOJ/U.S. Attorney’s Offices
– FBI
– DEA
– Other law enforcement agencies
• State
– Medicaid Program Integrity
– MFCUs
– State and local law enforcement agencies
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Staffing Trends
• Federal agencies affected by the sequester and on‐going budget issues
• State agencies have been largely unaffected by federal budget issues
• Many state enforcement agencies are increasing staff
Medicaid PI agencies and MFCUs
• Strengthening relationships and to prevent duplication of efforts
• Constant communication, both formal and informal
• CAF holds
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Technological Tools
• Increased use of technology to deter and detect fraud
– Phasing out of paper claims submissions for those providers who still use them, increased ability to use data analytics
– On‐site call‐ins or swipe cards to verify location for home health care and transportation services
– GPS/cell phone information
Electronic Medical Records
• If used properly can aid fraud detection and investigation
– Dates notes were made
– Track additions, changes, deletions
• Many contain features that are not ideal for fraud detection and investigation
– Allow changes without specific notation of the alteration
– Copy all information from prior visits into the notes
• Increase in computer forensics as in investigative aid
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Targeted Areas of Concern
• Focusing resources to areas of concern
– Behavioral health
– Home health
– E&M upcoding
– Short stay admissions
Provider issues
• Providers having unlicensed or non‐credential staff provide services.
• Group practices operating under individual MA number.
• Staff are not employees but contractual (1099’s)
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Drug Diversion
• Multi‐agency cooperation to identify and stop drug diversion
• National prescription drug database
– Will work best if providers use the database consistently
Multi‐State Investigations
• State and federal agencies conducting joint investigations of providers with multi‐state business
• States continue to adopt False Claims Acts
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Outreach to Local Agencies
• Outreach and training to local agencies to identify and report fraud, waste, and abuse
– Local prosecutors
– Local police
– Social services agencies
Outreach to others
• 1. Provider associations
• 2. The public
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