Upload File

december 2015 medicaid fraud false claims act sunset review legislative auditor’s conclusion: the...

  • Home
  • Documents
  • December 2015 Medicaid Fraud False Claims Act Sunset Review Legislative Auditor’s Conclusion: The Legislature should reauthorize the Medicaid Fraud False
11
December 2015 Medicaid Fraud False Claims Act Sunset Review Legislative Auditor’s Conclusion: The Legislature should reauthorize the Medicaid Fraud False Claims Act because it allows the state to pursue additional fraud cases, and recoveries have increased ark Fleming, JLARC Staff Proposed Final Report:

Upload: julius-hill

Post on 19-Jan-2016

218 views

Category:

Documents


0 download

Report

Tags:

TRANSCRIPT

Page 1: December 2015 Medicaid Fraud False Claims Act Sunset Review Legislative Auditor’s Conclusion: The Legislature should reauthorize the Medicaid Fraud False

December 2015

Medicaid Fraud False Claims Act Sunset Review

Legislative Auditor’s Conclusion:

The Legislature should reauthorize the Medicaid Fraud False Claims Act because it allows the state to pursue additional fraud cases, and recoveries have increased

Mark Fleming, JLARC Staff

Proposed Final Report:

Page 2: December 2015 Medicaid Fraud False Claims Act Sunset Review Legislative Auditor’s Conclusion: The Legislature should reauthorize the Medicaid Fraud False

Washington Medicaid is a $9.6 billion program (FY 2014) Program pays health care providers for services

to 1.75 million eligible Washingtonians

Federal government and state share costs Washington FY 2014 share: $4.0 billion

Medicaid fraud involves a health care provider knowingly submitting claims for payment to which the provider is not entitled

Medicaid Fraud False Claims Act Sunset Review December 2015 2/11

Page 3: December 2015 Medicaid Fraud False Claims Act Sunset Review Legislative Auditor’s Conclusion: The Legislature should reauthorize the Medicaid Fraud False

Three avenues to investigate potential Medicaid fraud1. Federal investigations: criminal and civil2. State criminal investigations3. State civil investigations

Authorized by Medicaid Fraud False Claims Act enacted in 2012

Expires in 2016 unless reauthorized by Legislature

Investigation, prosecution, and potential triple damages create disincentive for submitting false claims

Medicaid Fraud False Claims Act Sunset Review December 2015 3/11

Page 4: December 2015 Medicaid Fraud False Claims Act Sunset Review Legislative Auditor’s Conclusion: The Legislature should reauthorize the Medicaid Fraud False

Washington’s False Claims Act allows Attorney General to investigate civil fraud AGO has investigated 29 state-only civil cases of

Medicaid fraud since 2012 Without the False Claims Act, AGO could only

pursue criminal cases against fraud

AGO receives early notification and may participate actively in federal civil cases involving Washington providers

Provides opportunity to identify state interests and maximize recoveries from federal cases

Medicaid Fraud False Claims Act Sunset Review December 2015 4/11

Page 5: December 2015 Medicaid Fraud False Claims Act Sunset Review Legislative Auditor’s Conclusion: The Legislature should reauthorize the Medicaid Fraud False

Average annual fraud recoveries have increased

State Share

Federal Share

Average Annual Recoveries before Washington’s FCA

Average Annual Recoveries after Washington’s FCA

Total: $19.8 M

Total: $25.1 M

$12.7m

$12.4m28% Increase

Medicaid Fraud False Claims Act Sunset Review December 2015 5/11

$10.0m

$9.8m

Page 6: December 2015 Medicaid Fraud False Claims Act Sunset Review Legislative Auditor’s Conclusion: The Legislature should reauthorize the Medicaid Fraud False

State-only civil cases are cost effective

Medicaid Fraud False Claims Act Sunset Review December 2015

State share of recoveries:

$2.85 million

Each dollar spent on investigation

Returned $2.96 to the state

$State share of dollars

spent on investigations:$0.96 million

$$$

Source: JLARC staff analysis of 29 State-only civil cases, June 7, 2012 – May 31,2015

6/11

Page 7: December 2015 Medicaid Fraud False Claims Act Sunset Review Legislative Auditor’s Conclusion: The Legislature should reauthorize the Medicaid Fraud False

Private individuals may file civil actions under Washington’s False Claims Act

Known as qui tam cases Private individuals are called “relators”

May receive a share of any recovery resulting from case

AGO has option to intervene and pursue case If AGO declines to intervene, relator may

continue to pursue case Provision mirrors federal fraud control act

Medicaid Fraud False Claims Act Sunset Review December 2015 7/11

Page 8: December 2015 Medicaid Fraud False Claims Act Sunset Review Legislative Auditor’s Conclusion: The Legislature should reauthorize the Medicaid Fraud False

Seven qui tam cases filed since 2012None found by courts to be frivolous

AGO declined intervention

AGO decision pending

AGO settledRelator $292,800

$8,953

$3.65M

XX

Medicaid Fraud False Claims Act Sunset Review December 2015 8/11

Page 9: December 2015 Medicaid Fraud False Claims Act Sunset Review Legislative Auditor’s Conclusion: The Legislature should reauthorize the Medicaid Fraud False

If Washington eliminates qui tam

Qui tam is a central requirement for obtaining federal approval of a state Medicaid fraud control act

In absence of state qui tam provision, Washington would lose: Additional 10 percent of recoveries, and Early notice of federal qui tam actions involving

state Medicaid providers when the case is filed Providers will continue to be subject to federal

qui tam actions

Medicaid Fraud False Claims Act Sunset Review December 2015 9/11

Page 10: December 2015 Medicaid Fraud False Claims Act Sunset Review Legislative Auditor’s Conclusion: The Legislature should reauthorize the Medicaid Fraud False

Recommendation & Agency Response

Medicaid Fraud False Claims Act Sunset Review

Reauthorize the Medicaid Fraud False Claims Act, Chapter 74.66 RCW

The Legislature should:

AGO concurs

Note: The Office of Financial Management (OFM) responded that it did not have comments on this report

December 2015 10/11

Page 11: December 2015 Medicaid Fraud False Claims Act Sunset Review Legislative Auditor’s Conclusion: The Legislature should reauthorize the Medicaid Fraud False

Contact Information

Mark Fleming, Project [email protected] 360-786-5181

Valerie Whitener, Project [email protected] 360-786-5191

www.jlarc.leg.wa.gov

http://www.jlarc.leg.wa.gov/

STATE FALSE CLAIMS ACT SUMMARIES March …...Arkansas Medicaid Fraud Act (“AMFA”) (Ark. Code Ann. 555-101 to 555--114), which provides for - criminal sanctions in cases of Medicaid

Health care fraud stark law and false claim act

The lessons in this module, “Medicare and Medicaid Fraud ... · The lessons in this module, “Medicare and Medicaid Fraud and Abuse Prevention,” explain Medicare and Medicaid

The Mississippi Medicaid Fraud Control Unit (“Unit ...€¦ · the Medicaid Fraud Control Unit are directed. If you suspect that fraudulent activity involving Med-icaid providers

State False Claims Act Summaries....The Arkansas Medicaid Fraud False Claims Act (“AMFFCA”) (Ark. Code Ann. 20-77-901 to 20-77-911) is a civil statute that helps the state combat

Medicare and Medicaid Fraud & Abuse Prevention (Alaska)

Money Laundering Offences - sentencingcouncil.org.uk · Contents Applicability of guideline 4 Fraud 5 Fraud by false representation, fraud by failing to disclose information, fraud

Rapidly Increasing Criminal and Civil Monetary Penalties ......Medicaid fraud (e.g., Texas Medicaid Fraud Prevention Act) and consumer protection (e.g., West Virginia Consumer Protection

The False Claims Act: A Consumer's Tool to Combat Fraud

Medicaid Fraud Control Units 2013

Medicaid Fraud

Procurement Fraud - National Judicial Academy · 2016-09-06 · Procurement Fraud Forging documents, preparing false entries in enterprise systems or making false statements to obtain

VERMONT MEDICAID FRAUD AND RESIDENTIAL ABUSE UNIT … · 1 . 2016 ANNUAL REPORT NARRATIVE . In compliance with 42 C.F.R. § 1007.17(h), the Vermont Medicaid Fraud and Residential

Preventing and Recognizing Medicaid Fraud and Abuse

Member Rights and Responsibilities Medicaid Fraud and ... · • An individual does not report other insurance when applying for Medicaid • A non‐Medicaid recipient uses a Medicaid

Medicaid Fraud Control Units Fiscal Year 2015 Annual ... · Medicaid Fraud Control Units FY 2015 Annual Report (OEI-07-16-00050) 4 . Fraud cases accounted for 71 percent of convictions

September 2015 Medicaid Fraud False Claims Act Sunset Review Legislative Auditor’s Conclusion: The Legislature should reauthorize the Medicaid Fraud False

PREVENTION & PROSECUTION OF MEDICAID FRAUD AND RECIPIENT ABUSE MEDICAID FRAUD CONTROL UNIT Post Office Box 94005 Baton Rouge, Louisiana 70804-9005 Telephone:

Medicare, Medicaid Payment Policies, Fraud Authorities ... · Medicare, Medicaid Payment Policies, Fraud Authorities Enacted as Part of 21st Century Cures Act Written by: Gail Daubert,

COMBATING MEDICAID FRAUD IN NEW YORK STATE · ON MEDICAID FRAUD Senator Kemp Hannon, ... A Brief Overview of Medicaid 9 ... component in fighting fraud and wasteful practices at the

Fighting Medicare and Medicaid Fraud, Waste & Abuse · Medical LLC (Arriva) and its parent Alere Inc. (Alere) submitted or caused false claims to the Medicare program for medically

Medicaid Managed Care Integrity, Compliance, and Fraud ... · Medicaid Managed Care Integrity, Compliance, and Fraud Surveillance Timothy Champney, Ph.D. ... Top 40 Service Categories

Common Medicaid Billing Pitfalls - NJAMHA · ... Wealth Management . Common Medicaid ... Management Information System Overview • NJ Medicaid Fraud ... Medicaid Management Information

Medicaid Fraud Budget 2008

A Roadmap for Physicians Avoiding Medicare and Medicaid Fraud and Abuse As a physician you must be knowledgeable about the Medicare and Medicaid fraud

Louisiana Medicaid Fraud Control Unit Onsite Federal Review 2012

Medicaid Fraud Control Units Fiscal Year 2019 Annual ...Medicaid Fraud Control Units Fiscal Year 2019 Annual Report Medicaid Fraud Control Units (MFCUs or Units) investigate and prosecute

A Performance Audit of The Medicaid Fraud … of the Utah Legislative Auditor General i Digest of A Performance Audit of the Medicaid Fraud Control Unit The Utah Medicaid Fraud Control

Medicare and Medicaid ( Medi -Cal) Fraud

DECEPTIVE MARKETING, MEDICAID FRAUD, AND UNNECESSARY …

Medicaid Fraud Control Units Fiscal Year 2013 Annual ... · Medicaid Fraud Control Units Fiscal Year 2013 ... OEI-06-13-00340 . INTRODUCTION . This Medicaid Fraud Control Unit

Medicaid and Medicare Fraud, Waste and Abuse Training · compliant with the Fraud, Waste and Abuse training requirements, Medicaid and Medicare Plan ... Maintain records of training

A Performance Audit of The Medicaid Fraud Control Unit

Medicaid Fraud Database Structures

A Performance Audit of The Medicaid Fraud Control …le.utah.gov/audit/12_13rpt.pdfcase referrals that likely reduced ... Digest of a Performance Audit of the Medicaid Fraud ... -