• As California Medi-Cal Fraud Bid Awaits Final Approval, What Challenges Lie Ahead?

    October 3rd, 2017 by admin Categories: Blogs

    After nearly a year and a half of delays brought on by obscure procurement technicalities and small business preference scoring the Medi-Cal Program Integrity Data Analytics (MPIDA) program seems poised at last to move forward.

    Nearly 71 percent of all health care spending is paid out by taxpayers, but of the $100 billion paid out each year for the state’s Medicaid claims, called Medi-Cal in the Golden State, an alarming percentage of funds are lost each year due to fraud. It’s a multi-billion-per-year problem that’s only escalated as changing technology has provided criminals numerous methods for defrauding the state. U.S. Government Accountability Office (GAO) estimates Medicaid fraud nationally at 8% while other experts such as Harvard University’s Malcolm Sparrow suggest that improper payments account for 20 percent of spending in federal/state health care programs.

    What are the biggest challenges ahead in using MPIDA to fight Medi-Cal fraud? According to Anthony Cava at the California Office of Communications for the Department of Health Care Services, one of the biggest challenges arises from “the sheer size of the [Medi-Cal] program and the different ways people may defraud the program.” Said Cava, “As the Medi-Cal program evolves, so do the ways that criminals will innovate and try to exploit it.”

    To better combat these changing tactics, the DHCS recently moved to expand the use of data analytics. The effort will provide investigators additional tools for detecting fraudulent behaviors early and preventing fraudulent claims from being paid out by the state. “There will always be a place for spot checks and audits,” said Cava, “but shifting to a more proactive approach creates an opportunity to deter fraud and identify it before incurring big losses.”

    Folsom-based OnCcore Consulting, with partners Pondera Solutions from Gold River and LexisNexis, in winning the MPIDA bid, are tasked with providing the analytical muscle that investigators will need to more effectively track and shut down questionable Med-Cal claims.

    Although the technology will be a welcome boost to fraud prevention efforts, Cava acknowledges that data analytics “isn’t a magic bullet” solution to the issue. However, the proactive use of data to target scammers and prevent false claims could act as a deterrent, discouraging would-be fraudsters from trying to cheat the state.

    The only question remaining is when and how Californians can expect to see MPIDA at work. According to Cava, the federal Centers for Medicare & Medicaid Services (CMS) has not yet approved the contract, which was submitted for approval on August 4th. He confirmed that CMS typically takes up to 60 days “to review and approve contracts.” It’s possible that the official go-ahead for MPIDA might not be coming until early October.

    Should the contract finally be approved, MPIDA’s implementation process is expected take anywhere from three months to a year. Even with eyes fixed on MPIDA, Cava assured that Medi-Cal anti-fraud efforts are ongoing. “California’s Medi-Cal anti-fraud efforts are widely recognized among all state Medicaid programs for their innovation and multi-pronged approaches.”

    by Toni Matthews – El, TLTVnews Reporter

    Anonymous Commenting is Welcome. To have your name or website appear with your comment, fill out the form below. All Comments are moderated to prevent spam. Thanks for joining in the discussion!