For viewing pleasure, I shall go through this press release and identify the limitations of using data mining for the purposes of detection and preventing Medicaid fraud in child welfare in red.
HHS Announces New Tool to Help Fight Health Care Fraud in Florida
HHS Secretary Sebelius and Attorney General Holder to Co-Host Fraud Prevention Summit Tomorrow in Miami
U.S. Health and Human Services Secretary Kathleen Sebelius announced today that health care fraud fighters in the state of Florida will now have additional funding to help find potential fraud and abuse in the state’s Medicaid program through the use of Medicaid claims data.
The health care fraud fighters in Florida who are versed in the area of Medicaid fraud in child welfare, including those who are willing to import this expertise to the state, are typically grassroots organizations and lone parents whose parental rights have been terminated who have been made out to be dismissed on their cries of fraud in child welfare. Lacking the sophistication to participate in qualification of this additional funding, Medicaid fraud in child welfare will continue along its happy incremental increase slope.
Today, Secretary Sebelius approved Florida’s Medicaid waiver request to help fund a demonstration program that will allow the state’s Medicaid Fraud Control Unit (MFCU) to “mine” Medicaid Management Information System (MMIS) data to identify cases of potential Medicaid fraud.
The MFCU will rely upon subcontracting this data mining demonstration program to Maximus, Inc. With a reputation of being the "jeepers-creepers keeper" of the record, Maximus, Inc. does not have a very reliable track record when it come to skills, knowledge and abilities (I refer to as the "skas") when it comes to handling data.
Corporate Integrity Agreement between the HHS OIG and Maximus, Inc. 2007
Medicaid billing for many health care services in South Florida is disproportionately high compared to other parts of the country. Although significant progress has been made, fraudulent billing health care fraud continues to cost Medicaid millions of dollars.
Medicaid billing in child welfare for the state is proportional to the other States as the pattern exists in every state. Very little progress has been made in Florida regarding the aberrant billing practices in child welfare fraud which continues to cost Medicaid billions of dollars.
“To fight health care fraud, we need to coordinate all of the resources and data we can muster,” said Secretary Sebelius. “By allowing the state of Florida to use more information to find potential fraud in Medicaid, this waiver will improve Florida’s ability to effectively identify and combat fraud and abuse.”
There is a reason why there will never be a coordination of resources and data to end Medicaid fraud in child welfare because the child abuse propaganda marches to the tune of the imperialistic morality parade.
The announcement comes in advance of the Department of Health and Human Services and Department of Justice’s first Regional Health Care Fraud Prevention Summit being held tomorrow at the Knight Center in Miami, Fla.
The summit, which will feature keynotes remarks by U.S. Attorney General Eric Holder and Secretary Sebelius, kicks off the first in a series of day-long summits bringing together a wide array of federal, state, and local partners, beneficiaries, providers, and other interested parties to discuss innovative ways to eliminate fraud within the U.S. health care system.
As part of its efforts to coordinate the fight against fraud across the nation’s health care systems, including Medicaid and Medicare, data mining will allow Florida’s MFCU to sort electronic claims through the use of statistical models and intelligent technologies to uncover patterns and relationships. Using the identified patterns, investigators can review Medicaid claims activity and history to find abusive or abnormal use of services and billing that may be potentially fraudulent. Data mining is done with software programs which include algorithms that automatically analyze the MMIS data.
The HHS Inspector General reported to Congress just a few months ago that the MMIS data were not "timely, accurate, or comprehensive for detection of fraud, waste, and abuse." The MMIS data, handled by the unenlightened over at Maximus, Inc. is not the only database Florida has to execute the task of ending Medicaid fraud in child welfare.
There are other statistical methodologies that can easily be applied to detect patterns and relationships of fraud in child welfare. There are other databases and potential other databases that can be analyzed but will never see the light of day.
There is no oversight and no reporting avenues for fraud in child welfare. There is no exclusionary database in child welfare.
Currently, state MFCUs are prohibited from using federal Medicaid matching funds to detect potential fraud through routine claims review procedures such as screening of claims, analysis of billing practice patterns, or routinely verifying that billed services were actually received by patients, since these functions are a primary program operation function of the state Medicaid agency. Instead, MFCUs generally rely on referrals from the State Medicaid agency. The waiver approved today will allow the Florida MFCU to use federal matching funds to apply sophisticated electronic data mining tools that are beyond the scope of the claims review activities normally performed by the State Medicaid agency to identify potential fraud.
Currently, the MFCU is prohibited from ending Medicaid fraud in child welfare. The MFCU is located in the Office of the Attorney General. The Attorney General represents state agencies in dealing with child welfare. There exists an inherent conflict of interests for the MFCU to prosecute and recover Medicaid fraud in child welfare as it is the entity which defends the actions of the state agencies that have committed Medicaid fraud in child welfare.
In addition, there was nothing written in the final rules mandating MFCUs to address Medicaid fraud in child welfare. The final rules exclusively were designed to address the aged and "safe harbors", exceptions to fraud practices.
The Centers for Medicare & Medicaid Services (CMS) expects the MFCU to work closely with AHCA to ensure their collective efforts are effective. CMS will monitor the progress of this waiver in conjunction with the HHS Office of Inspector General, which has oversight of MFCUs.
CMS should expect to work closely with the people to ensure there collective efforts to end Medicaid fraud in child welfare will take effect, otherwise, Medicaid fraud (as well as all other frauds) in child welfare will only be addressed under the False Claims Act. Unfortunately, there are very few law firms that are willing to grasp the concept that fraud in child welfare even exists.
“The demonstration approved today will allow Florida’s Medicaid Fraud Control Unit to take full advantage of their expertise in detecting and investigating Medicaid fraud,” said CMS Administrator Don Berwick, M.D.
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