Detecting Medicaid fraud schemes and billing problems has netted Georgia a lot of money recently. Georgia’s Medicaid fraud unit recovered $57 million last fiscal...

Detecting Medicaid fraud schemes and billing problems has netted Georgia a lot of money recently.

Georgia’s Medicaid fraud unit recovered $57 million last fiscal year, the largest amount ever, a state official says.

Part of the reason for the higher collections is the fact that Georgia is now getting more money from settlements involving pharmaceutical companies, produced in joint investigations with other states and the federal government.

The state also has enhanced data-mining capability to detect cases of fraud and improper billing, said Charles Richards, director of the state’s Medicaid Fraud Control Unit.

Over the next year, “we’ll begin to see more prosecutions from data mining,’’ Richards said. “It’s becoming increasingly difficult for those who submit fraudulent Medicaid claims to fly under the radar.’’

Medicaid, the health insurance program for the poor and disabled, is jointly financed by individual states and the federal government. Because of that, the Medicaid recoveries in Georgia are split between the federal government and the program run by the state.

An example of the drug industry cases this year came in a settlement that Georgia, other states and the federal government reached with UCB Inc. over allegations that the company caused false or fraudulent claims for Keppra, a drug for epilepsy, to be submitted to the Medicaid program.

Georgia received $894,512 of the settlement in state and federal funds. The state’s portion was $371,171 of that amount. UCB pled guilty to one misdemeanor count of ‘’misbranding’’ in federal court.

In another case, APS Healthcare settled charges that it submitted false claims to Georgia Medicaid by not providing services it contracted for regarding disease management and case management. Georgia’s share of that $13 million settlement was $7.8 million. APS in a statement denied the allegations.

Richards said mental health is a common area for fraud. In a recent case, an Atlanta doctor, Robert Williams, was sentenced to one year and three months in prison for a fraud scheme to bilk Medicare and Medicaid.

Williams must pay $771,596 back to Medicare and $227,846 back to Georgia Medicaid.

From July 2007 through October 2009, Williams contracted with a medical services company to provide group psychological therapy to nursing home patients. Thousands of claims were submitted to Medicare and Georgia Medicaid seeking reimbursement for group psychological therapy, but in many cases, Williams did not actually provide the therapy.

“Some of the patients were dead at the time he claimed he provided services; others never received treatment,’’ said U.S. Attorney Sally Quillian Yates in a statement.

The Fraud Control team is now all under the state attorney general’s office, which has increased its efficiency, Richards said. “The attorney general has been very supportive in our efforts to combat Medicaid fraud,’’ Richards said.

The unit works with other agencies on Medicaid cases, including the Department of Community Health, which runs the program in the state.

That joint cooperation can be seen in cases where overpayments have been made by Medicaid to hospitals.

In one case, St. Joseph’s/Candler Health System reached a $2.7 million civil settlement related to Medicaid billing problems at its Savannah hospitals. The billing problem involved claims for patients who were enrolled in both Medicare and Medicaid. The health system denied any wrongdoing, and said it cooperated fully with the investigation.

“The state found no intent to defraud Medicare/Medicaid,’’ St. Joseph’s/Candler said in a statement. “The errors occurred due to a glitch in the state’s computer system, which created the overpayment.’’

Earlier, WellStar Health System reached a $2.7 million settlement in a similar case. WellStar said a flaw in claims processing software caused the problem. “The State specifically found no intent to defraud,” said WellStar, which admitted no wrongdoing as part of the settlement.

The Fraud Control Unit worked with the Department of Community Health’s Inspector General’s office in the hospital investigation.

The inspector general, Robert Finlayson, said recently that other hospitals are being examined for the overbilling problem.

Investigations also sometimes turn up fraud by individual beneficiaries, but that ‘‘is not a major part of our recovery work,’’ a DCH spokeswoman said.

In a case that’s separate from the Fraud Control Unit’s work, Community Health recently recovered more than $100 million in overpayments to the three care management organizations (CMOs) that administer  Medicaid to low-income Georgians.

The overpayment problem was found through the new Medicaid information technology system and improved audit procedures.

 


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Andy Miller

Andy Miller is editor and CEO of Georgia Health News

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