Medicaid companies are having a hard time enforcing payment suspensions on service providers versus which there are reliable claims of scams, according to a brand-new federal government guard dog report.
The report (PDF), from the Department of Health and Human Services’ Office of Inspector General, analyzed self-reported case information from both Medicaid companies and Medicaid Fraud reporting Control Units (MFCUs) for 2014. Throughout that time, 41 from the 56 firms stated they enforced 10 or fewer payment suspensions. In addition, simply 2 companies reported enforcing more than 50 payment suspensions each.
One factor for the low variety of payment suspensions is that many firms reported a couple of reliable accusations of scams, the report kept in mind. And for accusations considered to be trustworthy, many firms used what’s called an “excellent cause” exception, throughout which payments are not suspended while police examine a service provider.
There are benefits to taking the good-cause exception method. Agencies informed the OIG that it enables MFCUs to develop an enough level of proof to support payment suspensions, prevents signaling service providers to an examination, and guarantees that clients continue to gain access to health care services.
Medicaid companies also kept in mind that while payment suspensions are needed to be short-lived, scams examinations can typically drag out for months or years. That can put a payment suspension at danger for being reversed by a court or might own service providers out of business that ends up being innocent.
Regardless of these obstacles, however, the report kept in mind that Medicaid companies are establishing more official structures for reacting to trustworthy accusations of scams and consequently, suspending payments or using excellent cause exceptions. In addition, Medicaid companies and MFCUs are working together regularly.
To keep this momentum going, the OIG suggested that the Centers for Medicare & Medicaid Services use its information to determine Medicaid companies with a low variety of payment suspensions, then use them extra technical support to assist them completely use this program stability tool.