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Anthony Cirillo

Pew Charitable Trust Launches Database to Track State Campaigns Agst Medicaid Fraud

By February 22, 2013

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A first-of-its-kind database launched by the Pew Charitable Trusts (PCT) compiles and categorizes promising practices states employ to combat Medicaid fraud and abuse. These practices were cited by the Centers for Medicare & Medicaid Services (CMS) in the agency's state reviews.

States are targeting Medicaid fraud and abuse with an array of policies and tools. To help policy makers learn about steps taken in their state and across the country, the State Health Care Spending Project created an online database containing hundreds of practices found to be promising by state and federal Medicaid agencies.

Fraud and abuse in Medicaid waste dollars needed to deliver important health care services and can subject patients to unnecessary or ineffective tests and treatments.

These problems add pressure to state and federal budgets, too. In 2012, an estimated $19 billion--or 7 percent--of federal Medicaid funds were absorbed by "improper" expenditures, which include fraud and abuse as well as unintentional mistakes such as paperwork errors. Improper expenses drained an estimated $11 billion from states' Medicaid budgets in 2010, the most recent year for which data are available.

Drawing on reports from the federal Centers for Medicare & Medicaid Services (CMS), a database was built that makes it simple to learn about anti-fraud and abuse strategies used in a specific state or at different stages in Medicaid's interactions with providers and patients.

According to PCT, The CMS regularly invites states to identify which of their own approaches they believe are effective in reducing fraud, abuse, or wasteful errors in Medicaid programs. The agency publishes the findings, highlighting practices it considers "noteworthy."

The database centralizes the hundreds of anti-fraud and abuse practices, as featured in 70 CMS reports available online as of December 2012. Policy approaches from 49 states and the District of Columbia are included. The vast majority of states' actions are focused on providers (e.g., medical practices, pharmacies, managed care organizations). In general, states have three opportunities to protect against fraud and abuse among providers:

  • Screening them before and after they are accepted into the program;
  • Reviewing claims before they are paid; and
  • Reviewing claims after they are paid and recovering those deemed improper--known as "pay and chase."

The database organizes states' approaches into four categories that correspond to the three phases above plus a fourth containing measures that cut across them. The aim is to help ensure that more Medicaid funds support legitimate services that improve the health of the millions of Americans counting on the program.

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