If you were curious about whether the OIG had stepped up Medicaid audits as the pandemic’s effects began to wane, it’s time to stop wondering. The agency finalized 1,327 convictions last year, recovering $1.1 billion during 2022. And even though many practices equate audits solely with Medicare, the latest OIG report confirms the fact that Medicaid audits are frequent and fruitful.
Background: Last week, the OIG released its 26-page Medicaid Fraud Control Units Fiscal Year 2022 Annual Report. The report revealed that convictions for both fraud and patient neglect or abuse have risen since 2020, and noted that most Medicaid cases start as referrals from outside sources or by finding irregularities via data mining.
Check out a few highlights of the Medicaid audit findings.
Criminal Recoveries Accounted for $416 Million
The OIG investigates a wide variety of cases, with criminal violations being among the most visible. In many cases, criminal issues involve providers inappropriately billing both Medicare and Medicaid, and some of the recoveries in the latest report stem from such dual actions.
Example: The Texas Medicaid Fraud Control Unit investigated the CEO of a hospice facility who billed Medicare and Medicaid for hospice services not provided, not directed by a medical professional, or which were provided to individuals who weren’t hospice-eligible.
The hospice also used blank, pre-signed controlled substance prescriptions to distribute drugs that a physician didn’t order. This conviction resulted in about $82 million having to be paid back to the government, while four people involved face at least five years each in federal prison.
How to avoid this fate: Fraud like this never happens in a vacuum—a variety of staff members are involved in Medicaid claims, from billers and coders to revenue cycle experts and accounts receivable experts. If you see anything that looks unusual, flag it immediately. It’s possible that your colleagues aren’t committing fraud, but that you just need to shore up your operations. In other cases, you might find something unusual going on that should be taken up the chain and addressed immediately so you can rectify any wrongs before they snowball.
Dentists, Psychologists Faced Millions in Criminal Charges
The OIG broke down its criminal and civil recovery amounts by provider type. When classifying providers excluding physicians (MDs/DOs), the following clinicians appeared to rack up the highest dollar amounts in convictions:
Although those listed above saw the highest rates of recoveries, that doesn’t mean that other providers (like podiatrists, chiropractors, audiologists and more) weren’t investigated. However, it may mean that if you’re in one of the provider types listed above, it could be a good wake-up call indicating that it’s time to look at your operations and make sure you aren’t doing anything improper.
ER Specialists, Family Practitioners Topped the List of Doctors Facing Charges
When the OIG broke down its recoveries based on physician specialties, family practice providers were far and away in the lead when it came to criminal recoveries, while emergency medicine practices topped other specialists in terms of civil recoveries.
Some specialists, like ophthalmologists, geriatricians, and allergists saw less than $5,000 in recoveries last year. However, it’s important never to drop your guard, even if your specialty wasn’t among those with the highest recoveries.
Your practice can’t afford to fail a Medicaid audit—that’s why expert Owen Dahl, LFACHE, CHBC, LSSMBB, is here to help. During his online training, “Stop Costly Medicare/Medicaid Patient Billing Errors,” you’ll get real-world examples of how to stay on the right side of the law for QMB patients. Register today!
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