Services

  • Medicaid Program Integrity Services

    • Unique Characteristics of the Medicaid Program that Increase Fraud, Waste and Abuse  More>

  • Medicaid Fraud Audit Defense System Solution

    • Fraud Audit Defense Solution More>

  • Medicaid Waste and Abuse Abatement System Solution

    • Waste and Abuse Abatement Solution More>

  • Regulatory compliance risk assessment service for healthcare providers

  • Fraud audit and investigation service for public and private sector clients

  • Expert consultation in criminal diversion of prescription drugs

 

Unique Characteristics of the Medicaid Program that Increase Fraud, Waste and Abuse:

The transfer of the U.S. Medicaid population from direct state pay to a capitated managed care payment model has created a need for efficient, affordable and scalable healthcare fraud, waste and abuse audit services.

 

Most managed care organizations have only joined the Medicaid program in the last 5 to 10 years.  They are still learning about the unique characteristics of this program that increase the risk of loss from fraud, waste and abuse.

 

The Medicaid population includes many recipients who are in particularly vulnerable circumstances due to low income, physical and mental health disabilities, substance use disorders and other issues.  These issues make them targets for exploitation by individuals engaged in criminal fraud schemes, such as:

  •  Buying back expensive medication from Medicaid patients for cash.
  •  Cash payments to Medicaid patients to undergo unnecessary treatments.

  •  Cash payments to Medicaid patients for their recipient ID number, address, date of birth and other data, to be used by fraudulent “Medicaid Mills” that submit completely fraudulent claims.

 

 Fraud Audit Defense Solution:

  • To address these issues, managed care organizations need CPA audit managers with extensive Medicaid program regulatory enforcement experience to create a proactive Fraud Audit Defense System.  

  • We have a team of former New York State Attorney General Medicaid Fraud Control Unit Audit Managers who have developed a comprehensive Fraud Audit Defense System for our managed care clients.

  • It would be cost prohibitive and difficult for MCOs to recruit and maintain internal staff with this level of experience

  • Outsourcing this function allows for the immediate implementation of an economical system of provider fraud detection and audits:

    •  We have historical minimum rates of return of 7 to 1  

    •  Clients can recover overpayments obtained through fraud.

    •  Clients will also benefit from future fraud, waste and abuse cost avoidance.

  •  Our proactive Fraud Audit Defense System will:

    •  Create a reputation for the MCO that deters new fraudulent activity.

    •  Increase investor confidence in the MCO.

    •  Create valuable good will with government regulators

 

Waste and Abuse Abatement Solution

 

  • Another issue unique to the Medicaid program is the fact that low reimbursement rates make it difficult to build and maintain an adequate network of doctors and ordered service providers.

  • Our innovative Waste & Abuse Abatement System includes a continuing process of program integrity audits.  This is the most economical approach for our MCO clients who want to keep network providers in line with proper claims and coding procedures

  • This process reviews, audits and corrects aberrant claims and coding practices by network providers without reducing the size of the client’s network through unnecessary exclusions.

  • Our staff includes former government healthcare program CPA audit managers with over 30 years of very specific experience in developing and managing audit and regulatory compliance review programs.

  • These former New York State Attorney General Medicaid Fraud Control Unit managers work well with the data analytic staff of managed care organizations to select high value targets for audit and review.

  • Our audit and review process is efficient and minimally intrusive, utilizing electronic healthcare records; statistical sampling; and HIPAA secure data rooms for the transfer of medical charts and other records containing protected health information.    

CONTACT US

Email:     wmcgoldrick@wmcglaw.com
Address: 
 
365 Stewart Avenue, #B9
              Garden City, New York, 11530
Phone:  (516) 872-8300

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