A recent revelation has sparked concern among Minnesotans regarding the state's approach to Medicaid fraud detection. The Minnesota Department of Human Services (DHS) has implemented a new process to tackle potential fraud, but here's the catch: it's only reviewing claims for a small fraction of Medicaid enrollees.
The state has contracted Optum, a subsidiary of UnitedHealth Group, to conduct an enhanced prepayment review for 14 programs deemed high-risk. This review began in December, but it covers only about 20% of Medicaid enrollees.
The Big Question: Why is the majority of enrollees' claims left unchecked?
It all boils down to the fee-for-service model. DHS directly reimburses providers for claims under this model, but data shows that services for most enrollees (over 80%) are billed to and reimbursed by Managed Care Organizations (MCOs), not DHS.
So, the current review process is not catching potential fraud for the vast majority of Medicaid enrollees.
During a news conference, 5 EYEWITNESS NEWS raised this concern, questioning why a prepayment review, designed to tackle fraud, would exclude such a significant portion of claims.
Deputy Commissioner John Connolly acknowledged that the current scope is limited to the fee-for-service program, but expressed hopes to expand the review across the entire program.
But here's where it gets controversial: Connolly confirmed that MCOs have the majority of Medicaid enrollment, yet the onus is on insurers to detect and prevent fraud in claims billed to them.
And this is the part most people miss: DHS, as the administrator of Medicaid funds, has the authority to recover paid claims directly from MCOs if deemed improper.
In an email following the news conference, DHS provided additional details, stating that MCOs are contractually required to maintain special investigation units (SIUs) to address fraud. DHS oversees these SIUs and has the power to recover payments.
So, while DHS is taking steps to address fraud, the current review process leaves a significant gap.
What are your thoughts on this? Is this an effective approach to tackling Medicaid fraud, or is there room for improvement? We'd love to hear your opinions in the comments!
