Forensics Journal - Stevenson University 2015 | Page 72

STEVENSON UNIVERSITY

due to the rampant uptick in Medicaid fraud far surpassing other
types of federally-funded waste, it was imperative for legislators to
create solutions similar to those designed for Medicare (Secunda,
2009, p. 495). In 2005, Congress enacted the Deficit Reduction
Act (DRA) which, in part, mandated the creation of the Medicaid
Integrity Program. Very similar to the Medicare Integrity Program,
the Medicaid Integrity Program granted CMS the authority to
contract with private entities to combat Medicaid fraud, waste and
abuse through claims review, audits, overpayment determinations,
and provider education regarding program integrity and care quality
standards.

identify and analyze areas where fraud has or potentially will occur.
When target areas of claims with potential or probable fraud, waste
and abuse are discovered, Audit MICs are responsible for auditing and
reviewing the medical and financial documentation and information
associated with the claims. They report their findings, including any
overpayments, and refer fraud cases to the OIG. Education MICs are
tasked with summarizing the fraud, waste or abuse issues determined
by the Review and Audit MICs to educate Medicaid program
participants i.e. providers, medical supply companies, hospitals and
pharmacies regarding payment, program integrity and care quality
issues, expectations and requirements (Beik, 2011, p. 126).

At its creation and to date, the Medicaid Integrity Program operates
on several foundational principles. To successfully combat Medicaid
fraud, program partners, called Medicaid Integrity Contractors
(MICs) must be accountable for their fraud, waste and abuse
discovery operations while maintaining ongoing collaborations
with other internal and external partners and stakeholders to include:
Federal contacts, State Medicaid programs and the mining entities
responsible for providing the contract with pertinent provider and
beneficiary data. MICs must also have access to national leadership
associated with program integrity, such as HHS, OIG, DOJ and
CMS, and must be flexible to accommodate the ever-changing
healthcare arena and to combat continuously evolving Medicaid
fraud, waste and abuse (Green & Rowell, 2006, p. 119).

Since their enactment, HCFAC and the DRA have successfully
recovered and saved the Federal government large amounts of
program monies. Approximately $1.50 is saved or recovered for
every $1 spent on fraud and waste detection, control and prevention
efforts. As more money is saved or recovered, more money is available
for redistribution to programs i.e. the Medicaid and Medicare
Integrity Contracts to combat fraud, waste and abuse (Executive
Office, 2014, p. 118). However, Medicaid costs are expected to
grow an average rate of 6 percent annually for the next several years
and will balloon much larger after the Affordable Health Care Act
expands population enrollments (Bowman & Kearney, 1990, p.
475). If the cost of Medicaid program integrity efforts remains as-is,
coupled with projected increases in fraudulent spending, states
and the Federal government will experience an even greater fiscal
burden. While this reactive approach to discovering past Medicaid
and Medicare fraud, waste and abuse has undoubtedly recovered and
saved Federal and state governments large and valuable amounts of
program dollars, only preventative solutions can provide the type of
fiscal stability needed for these programs.

While state Medicare and Medicaid policy and regulation varies
widely across the country, one standard for all states exists:
responsibility to report their program data and statistics to the State
and Federal programs. This information details the number of state
program recipients, each beneficiary’s demographic information,
detailed accounts of the services received, and services billed to and
paid by Medicaid or Medicare. Essentially, if a beneficiary receives
even one dollar of Medicaid or Medicare services in the form of
prescription drugs, hospital or doctor visits or durable medical
equipment, every aspect of that service is recorded by the provider
and given to the state. This information includes the dates of service,
what types of services were provided, the doctor who provided the
services, any codes the doctor used to bill the services, the amount the
doctor or facility billed to the program and the amount the program
paid back to the provider for their services. This information is then
converted into complex data sheets collected and stored by the states
and shared with the Federal government. Both the states and the
Federal government relay this information to Medicaid or Medicare
Program Integrity partners (Thompson & Dilulio, 1998, p. 288).

CONCLUSION: THE FUTURE OF PROGRAM INTEGRITY
Not all potential fraud can be conceived and prevented before
motivated criminals find ways to infiltrate and exploit the system,
so data analysis of past fraud can be helpful in identifying those areas
most susceptible to future abuse. Reactive policy creation does have
advantages because, “with reactive policy, one gets the benefit of
observing the policy issues over time, and vetting the policy concerns,
before making changes,” similar to retrospective fraud identification
(Fiore, 2014, p. 1). However, predictive and preventative solutions
do have the ability to view fraud, waste and abuse as outdated and
exceptional characteristics of the Medicaid and Medicare programs
rather than the norm.
A first step in bolstering fraud prevention is to make it harder for
those with a propensity or history of committing fraud or creating
or participating in deceitful financial schemes to obtain access to
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