Medicaid Insurers Could Be Doing More to Catch Fraud and Abuse: Report
Health Care

Medicaid Insurers Could Be Doing More to Catch Fraud and Abuse: Report

FlickrMike Bitzenhofer

Medicaid insurers could be doing more to prevent fraud, waste and abuse that cost states billions of dollars a year, according to a new report released by the Office of Inspector General of the Department of Health and Human Services.

Managed care organizations, which serve more than 80 percent of Medicaid enrollees, are responsible for reporting cases of suspected fraud or abuse to state Medicaid officials. The report looked at data from the insurer with the greatest Medicaid spending in each of the 38 states that provide managed care. The 38 plans together received $62.2 billion in federal and state Medicaid money in 2015.

The analysis found that a seven of the managed care organizations examined referred fewer than 30 suspected cases of fraud or abuse in 2015, compared to a median of 106 cases across all insurers studied. A third of the health plans examined referred fewer than 10 cases of suspected fraud or abuse, and two insurers did not refer a single case.

In addition, some health plans terminated providers from their networks but did not inform officials, leaving open the possibility that those providers would defraud other plans. Medicaid regulations now require insurers to tell states about such terminations within 30 days, according to the report.

In some cases, the insurers did not identify and recover overpayments. The 38 insurers studied identified $57.8 million in overpayments due to fraud or abuse in 2015, but recovered just 22 percent of those overpayments.