- New Jersey improperly claimed at least $94.8 million in Medicaid reimbursement claims, according to a recent estimate from HHS' Office of Inspector General.
- Out of 100 claims from a random sample OIG investigated, 92 did not comply with federal or state requirements. Of the 92 non-compliant claims, 19 contained more than one deficiency, OIG stated.
- "The deficiencies occurred because the state agency did not adequately monitor the partial care services program to ensure that providers complied with these requirements," OIG stated.
OIG recommended that the state refund the millions of dollars to the federal government as well as issue guidance to the partial care provider community and improve its monitoring of partial care providers to ensure compliance with federal and state requirements.
According to OIG's report, the state disagreed with the recommendation to refund the money.
While this was a review from OIG and not a takedown of fraud from the Department of Justice, the report underscores the amount of fraud that the Medicare and Medicaid programs can experience. This summer, DOJ charged three healthcare professionals with conspiracy, obstruction, money laundering and healthcare fraud in a Miami-area scheme that bilked Medicare and Medicaid of more than $1 billion over 14 years. A month earlier, DOJ pressed charges against 301 defendants in 36 federal judicial districts for their alleged participation in Medicare fraud cases involving about $900 million in false billings.
Recently, Venson Wallin, consulting managing director at accounting firm BDO, shared with Healthcare Dive some tips to avoid healthcare fraud. Relating to to healthcare data, he said administrators don’t want to be surprised if the data point to audit records or documentation leading to embarrassing results or banishment from a Medicare program. “You need to know what’s going on in your shop from a data perspective,” Wallin said. There needs to be monitoring and tracking of the billing, claims data.