Nurses help fight Medicaid fraud

By Mike Miliard
09:40 AM

Florida is famous for its sunshine, but it's infamous for its Medicaid fraud. With the fourth largest program in the country, covering more than 2.1 million people, the state loses as much as $3.2 billion in fraudulent claims each year.

Indeed, it's not uncommon in the state for healthcare providers to become certified by Medicaid, and then begin bilking the program. Miami/Dade with a population of 2.5 million has as many home health agencies as California with 38 million people. And the average home health patient in Miami receives twice as many taxpayer-funded services as the typical Florida patient.

"Since we have the worst problem in the nation," said state senator Don Gaetz, "we need the most effective solution."

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Gaetz was speaking of an anti-fraud bill he'd co-sponsored, that would give the Florida Agency for Health Care Administration (AHCA) more tools to fight against fraud. The bill passed last May, ensuring "that taxpayer dollars are spent wisely,” said Holly Benson, Secretary of the AHCA, and helping "identify and keep the bad guys out."
One of the results of the new bill is a new agreement between AHCA and Sandata, a Port Washington, N.Y-based maker of IT solutions for home health and human service agencies. Using interactive voice biometric speaker verification technology Sandata's Telephonic Home Health Service Delivery Monitoring and Verification (DMV) pilot project will enable the Florida Medicaid program to verify that home health services were actually delivered to the Medicaid recipient.

Beginning July 1, 2010, Sandata will work with all home health agencies in Miami-Dade County to:

  • Confirm home health visits by taking calls from home health agency personnel (nurses and home health aides) who directly provide services to Medicaid recipients at the beginning and end of each home health visit using the Medicaid recipient's home telephone. If the Medicaid recipient does not have an available telephone, Sandata has alternative processes for tracking delivery of services;
  • Generate claims for home health visits through its Santrax Payor Management system and ensure that the service delivery information is consistent with the prior authorization in the Florida Medicaid Management Information System; and
  • Provide access to a Web based portal allowing providers to schedule visits, view visits provided by employees and confirm the accuracy of billing records before they are submitted to the agency's fiscal agent.

"Our technology systems prevent fraud and abuse," said Sandata CEO Harold Blue. "When a nurse or a nurse aide shows up at someone's home to take care of that patient, they pick up a land line or a cell phone, they call an 800 number and then they log in with their own personal PIN so we know they've arrived at that house at that certain time.

"Then they go about and do their work, they take care of that patient, and then when they're ready to leave the patient's home, they call that 800 number again, they log back in and put their PIN number, and at the time of leaving they put in the tasks that they performed for the patient."

"The Agency only pays for the ‘5 rights’ – the right service provided, at the right location, at the right time, for the right patient, by the right caregiver," said AHCA secretary Thomas W. Arnold. "Medicaid fraud is an important priority for our program. I am pleased that this project is under way, giving us one more tool to ensure that taxpayers' dollars are spent only on services actually provided to recipients." 

"These states are hurting. The economy is putting a squeeze on them," adds Blue. "This allows then to pay the nurse and nurse aides for the actual hours that they're taking care of the patient, and will clearly cut down on fraud, abuse and waste."

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