States need better Medicare data to fight Medicaid fraud

While conducting Medicaid fraud audits costs the government five times more than the amount it finds, states need better Medicare data to keep fraudulent providers out of their Medicaid programs and prevent financial waste, Stateline reported.

Dual-eligible claims represent a majority of Medicaid spending. States therefore need the ability to cross-check Medicaid provider and claims data with Medicare data, and in real-time, the article noted. According to Arizona Inspector General Glenn Prager, to make Medicare data more useful to Medicaid investigators, it must be available within 90-days.

Billing for dual-eligible beneficiaries is vulnerable particularly to fraud and abuse, largely because their care is funded separately. For example, ambulance companies charge Medicaid to transport elders and adults with disabilities to the emergency room, and then Medicare foots their hospital bills. As a result, ambulance company owners and operators can bill Medicare for millions of dollars for ambulance rides that are medically unnecessary or never occur.

Further highlighting data problems, the National Association of Medicaid Directors last month urged the federal government to improve Medicaid's access to Medicare data to reduce Medicaid fraud and abuse, as well as improve care for Medicaid and low-income Medicare patients.

"Specifically, states face overly burdensome and costly operational hurdles in accessing Medicare data; they must navigate inconsistent federal policies for obtaining the data; and they lack a mechanism that translates and diffuses any successful state experiences with obtaining and utilizing Medicare data," it said in a report.

To better integrate Medicare and Medicaid data, states should be able to share background checks and other information on providers who participate in Medicaid but also serve Medicare patients, especially providers who are under investigation or already kicked out of Medicare, Stateline noted.

For more information:
- read the Stateline article
- here's the NAMD report (.pdf)

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