Robin Mathias’s presentation at the 11th Annual Medicaid Managed Care Conference focused on how managed Medicaid health plans, state Medicaid agencies and provider networks can fight fraud by creating comprehensive fraud control programs that go far beyond fraud detection software.

Not only is 10-25% of health spending fraudulent, at least as much spending is legal but wasteful. Managed care programs that proactively identify, investigate and deter fraud, waste and abuse will gain a competitive edge and stronger voice in how Medicaid controls managed care fraud. Our workshop leader discusses why you need to take action to stop fraud and how to create a fraud control plan that will save you money.

Implementing comprehensive fraud control requires a cultural shift that makes fraud control part of everyone?s job. CEOs, medical directors, analysts, provider enrollment staff, enrollment brokers and claims processors all have important roles.

Initially, Medicaid agencies assumed they were not responsible for controlling fraud in managed care. The general consensus was that breaking the direct link between fees and service, would make managed care naturally immune to fraud. And even if there was some fraud, it would be up to the managed care organization to find it as part of controlling costs.

The reality is that much of managed care is vulnerable to the same scams as fee-for-service Medicaid and most managed care organizations are doing little to stop fraud. As Medicaid fraud control becomes more sophisticated and effective, fraud will shift to where there are fewer controls. Medicaid managed care plans are an easy target.

The good news is managed care plans can work with Medicaid programs to cut costs by reducing fraud. There are great opportunities to share information and information systems. The first step is making fraud control a priority and agreeing to work together.
The workshop leader will discuss economic incentives that invite fraud and how to identify and change those incentives. She?ll also discuss controls you can implement immediately and new ways of thinking about and finding fraud.

The workshop provides a forum for participants to present healthcare fraud questions and issues and discuss a variety of practical solutions. At the end of this workshop, participants have a more thorough understanding of how fraud affects their organization, how to create a comprehensive plan to stop it and what role they can play in fraud control.