Audit: Medicaid fraud unit must crack down
CHARLESTON, W.Va. -- With a backlog of 171 cases -- including 23 complaints dating back to 2009 or earlier -- the West Virginia Medicaid Fraud Control Unit is still not doing enough to crack down on overpayments or improper payments to Medicaid providers, a legislative audit released Wednesday concludes.
"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.
Nancy Adkins, Medicaid commissioner for the state's Bureau of Medical Services, said the Fraud Control Unit is hiring additional staff and is adding data-analysis technology that should be online early next year to flag unusual billing patterns and claims.
"We are looking at technology to help us work smarter," she said.
Adkins said the fraud unit has an annual operating budget of about $1 million, but last year recovered nearly $20 million in overpayments.
Wednesday's audit was a follow-up to a 2007 study, and it found that the unit was in compliance or partial compliance with many of the recommendations from the earlier audit.
That included improving communications between the BMS and the fraud unit, and conducting background checks of so-called high-risk providers, including durable medical equipment companies, transportation services and home-health agencies.
However, the fraud unit continues to balk at a recommendation to conduct pre-payment reviews of claims submitted by providers who previously have been investigated for billing fraud.
Adkins said only a handful of states conduct such pre-payment reviews because of the cost.
"It may cost us more than we would actually recoup," she said. "Not many states do pre-payment reviews because of the resources it requires."
There also is a concern that pre-payment reviews would cause providers to stop accepting Medicaid patients, she said.
"We do post-payment review," she said. "We pay it and, if we think it's inappropriate, we go after it."
In a related issue Wednesday, House Finance Chairman Brent Boggs, D-Braxton, continued to raise concerns about a large backlog of individuals on the wait-list to qualify for Medicaid Aged and Disabled Waivers, which provides in-home care services.
As of July 31, there were 2,347 West Virginians waiting for the 6,275 slots available, according to BMS reports.
In 2012-13, 246 people were removed from the wait-list because they had died. Comparatively, only 204 people moved off the wait-list into the waiver program that year.
"So they passed away without receiving any services while on the wait list," Boggs said of the 246.
Tina Bailes, Department of Health and Human Resources deputy commissioner for finance, told the Joint Committee on Government and Finance it would take an additional $12 million of state funding to clear the wait list.
Senate President Jeff Kessler, D-Marshall, said a key problem is that, under federal regulations, once a slot becomes vacant, it cannot be filled again until the next fiscal year. If a participant dies or is transferred to a nursing home on July 2, that slot remains vacant for 364 days, he said.
"It seems like a lot of people could be helped now, instead of a year from now, when they may be dead," he said.
Boggs said correcting problems with the waiver program is a cost-effectiveness issue, since people denied in-home care frequently end up in nursing homes at a much higher cost to the state.
"I don't know why we're not taking advantage of a program that has a 3-to-1 federal match," Boggs said of the waiver program.
Reach Phil Kabler at firstname.lastname@example.org or 304-348-1220.