Making Medicaid work

Our view: To fight the rising costs of health care insurance for the poor, Maryland needs broader authority to go after providers who commit fraud

With talk in Congress of further expanding Medicaid as part of President Barack Obama's health care reform effort, Maryland needs to get its fiscal house in an efficient order. Governor O'Malley must not only convince lawmakers to give the state health department the tools to stop fraud this year, he must also ensure that Medicaid isn't mired in waste and sloppy accounting practices that can be just as costly. Readers respond A noble, yet mis-targeted initiative. Although punitive measures help, prevention and use of technology are far superior in reducing this problem. States cannot afford to prosecute frauds below $50,000, and this leaves an umbrella for criminals to operate under. The issue is that lawmakers think in terms of catching criminals and punishing them, rather than cost-effective prevention. Such tools are in use today, and I will be pleased to appear before the legislature on how to implement them. Jeff Leston   Why are fraudulent claims processed as legitimate and paid in full? What kind of ID numbers do the fraudulent claimants use? Are they IDs stolen from participating providers? For electronic remittances to be made, Medicaid needs bank account numbers. For remittances to be mailed, physical addresses are needed. Fraud can only occur if claims processors are asleep at the wheel, if databases with provider information are incomplete or inaccurate or if spurious providers, absent from the databases, are treated as participating in Medicaid and sent checks for services never rendered. Outrageous. The cleanup should occur at the level of data entry, with frequent updating of information already in the system. Incompetent claims processors should be weeded out, and vigilance should be the rule when it comes to remittances. What constitutes a suspicious claim should be clearly defined, and all such claims should be red-flagged. Random audits and requests for documentation will keep the fraudsters at bay, but none of this seems to be happening. The attitude in the hallways of Maryland Medicaid is lackadaisical. Claims are processed and paid in full with nary a thought expended on all the details that will thwart the cheats. Therein lies the problem - and you want to go after the thugs after they have whistled all the way to the bank. Providers are right. Knowing the kind of people who run Maryland Medicaid, they will for sure target providers for innocent errors made while the humbugs sit pretty. A Provider