For fiscal year 2017, the Mississippi Division of Medicaid (DOM) recovered in excess of $8.6 million through various audits of medical claims paid to health-care providers. Recouping funds can result from a range of factors that involve the payment or responsibilities of providers or beneficiaries, or even outright fraud, such as billing for health services a beneficiary did not receive from a provider.
DOM monitors money spent in order to hold both beneficiaries and providers accountable for using the program appropriately.
Not only does DOM serve a large population of Mississippians who need access to health coverage, the agency also handles a significant percentage of the state budget. The budget for Medicaid is approximately $6 billion, which is a combination of state funds and matching federal dollars.
“This is federal and state money that we have a responsibility to recover, but at the same time we put a lot of effort into preventing it in the first place through policy and system changes,” said Dr. David J. Dzielak, executive director of DOM.
Funds are recovered through a broad range of activities. DOM is federally required to make these reviews and recoveries, and the agency routinely interacts with other agencies, such as the Office of Inspector General, the Department of Justice, and multiple Boards of Licensure.
Most directly, DOM works closely with the Medicaid Fraud Control Unit in the office of the Attorney General.
“Our partnership with the Division of Medicaid, specifically the Program Integrity Unit, plays a key role in continuing the fight against fraud in healthcare benefit programs,” said Attorney General Jim Hood. “The Medicaid Fraud Control Unit staff is committed to protecting our most vulnerable citizens and the resources needed to serve them. Not only does our partnership allow for the prosecution of those defrauding the program and the prosecution of those abusing and neglecting patients, but it also allows court ordered restitution and penalties in both criminal and civil cases.”
Not all funds are recovered by Program Integrity unit. Other office areas within DOM review different types of possible violations including beneficiaries’ failure to notify DOM of substantial changes that affect their eligibility and DOM’s payment responsibility. For example, the Office of Third Party Liability (TPL) uses a variety of tools to ensure Medicaid is the payer of last resort, and recovers any dollars Medicaid paid prior to the knowledge of a liable third party. The offices of Legal Services and Financial and Performance Review also perform a number of recovery actions.
Looking back over fiscal year 2017, Medicaid had the following activity:
- Approximately $6.3 million recovered through TPL and Legal.
- Approximately $1.6 million recovered through Program Integrity.
- Approximately $680,000 recovered through Financial and Performance Review.
- Seven cases referred to the Medicaid Fraud Control Unit in the attorney general’s office; DOM has identified $3.1 million as improper billing associated to those cases.
- Hundreds of cases opened for investigation.
Every dollar lost to the misuse of Medicaid benefits, is one less dollar available to fund programs providing essential health services for vulnerable Mississippians.