Mathias Consulting - News and Commentary

Missouri AG Nixon Recovers $462926 In Ongoing Medicaid Fraud

Thu, 9 Aug 2007 19:31:17 -0700

Attorney General’s News Release

August 7, 2007
Nixon recovers $462,926 in ongoing Medicaid fraud investigation in Dekalb County

Jefferson City, Mo. — Attorney General Jay Nixon announced today that the Missouri Medicaid program will be receiving $462,926 from a pharmacy in DeKalb County that is under investigation for Medicaid fraud. Nixon said the Medicaid Fraud Control Unit in his office has recovered the money from the Randolph Drug Store in Maysville.

Texas Physician Sentenced for $10 Million Scam

Thu, 9 Aug 2007 19:18:06 -0700

Press Release
The United States Attorney’s Office
Southern District of Texas

August 6, 2007

LOCAL PHYSICIAN SENTENCED TO PRISON FOR DEFRAUDING INSURANCE COMPANIES OF $10 MILLION

(HOUSTON) Dr. Ira Klein, a physician who specialized in treating Hepatitis C patients, has been sentenced to more than 11 years in federal prison, without parole, for health care and mail fraud, United States Attorney Don DeGabrielle announced today.

New Nerve Test, a Moneymaker, Divides Doctors (New York Times)

Tue, 14 Nov 2006 06:50:50 -0800

Any test which doctors provide themselves (self-referral) is an opportunity for fraud. To identify suspect cases, measure the number of tests per 1,000 patients for doctors performing the test themselves, compared to those who refer patients to another provider. You may need to make adjustments for patient diagnosis or health status.

Of course looking to evidence is most important. Are these doctors qualified to perform the service? Is the diagnostic test effective as a screening tool or should its uses be more limited? Does the test result in more treatment? Is the treatment effective?

Here are some highlights from an article from the New York Times about a product with high fraud potential:

It's been a long time

Thu, 26 Oct 2006 21:22:54 -0700

It’s been a long time since I’ve sent out a newsletter. Many of you have probably never received a newsletter from me and don’t even remember signing up for them. This month, I’m sending you articles that focus mostly on Medicaid fraud, from old standards like transportation fraud to new themes like fraud rings in New York. Check the website next week for a more thorough examination of transportation fraud and best practices for fighting it. Enjoy!

To change your subscription visit: subscriptions

Dentist who diagnosed nonexistent cavities reaches agreement - FtWayne.com

Thu, 26 Oct 2006 20:43:51 -0700

AP Wire | 10/24/2006 | Dentist who diagnosed nonexistent cavities reaches agreement

“ANGOLA, Ind. - A dentist accused of diagnosing cavities that did not exist will not face prison time, according to an agreement filed in Steuben Circuit Court.

Investigators Arrest Pharmacy Owner Indicted For Medicaid Fraud

Thu, 26 Oct 2006 20:36:21 -0700

Tuesday, October 24, 2006
Attorney General Abbott’s Investigators Arrest Pharmacy Owner Indicted For Medicaid Fraud

Erasmo Cantu arrested in Brownsville; over $5 million in theft alleged

BROWNSVILLE - Texas Attorney General Greg Abbott today announced the arrest of a Cameron County pharmacy owner who was indicted by a grand jury on Oct. 18 for felony offenses involving more than $5 million in alleged fraudulent Medicaid reimbursements for excessive prescription refills.

STATE INVESTIGATION REVEALS WIDESPREAD MEDICAID FRAUD

Thu, 26 Oct 2006 08:18:22 -0700

Department of Law
The State Capitol
Albany, NY 12224

For More Information:
518.473.5525

For Immediate Release
October 25, 2006

STATE INVESTIGATION REVEALS WIDESPREAD MEDICAID FRAUD

Doctor and pharmacists among those indicted for multi-million dollar fraud

Attorney General Eliot Spitzer and State Medicaid Inspector General Kimberly O’Connor today announced that, after a 4-month undercover investigation, prosecutors and investigators have dismantled a Medicaid fraud ring involving a doctor, pharmacists, several city pharmacies, millions in fraudulent Medicaid billings and large monetary transfers to individuals in Pakistan.

Major Medicaid Fraud Ring Dismantled - North Country Gazette

Thu, 26 Oct 2006 19:59:13 -0700

Major Medicaid Fraud Ring Dismantled - North Country Gazette -
“ALBANY-Following after a four-month undercover investigation conducted by the state Attorney General’s office and the state Medicaid Inspector General’s office, prosecutors and investigators have dismantled a Medicaid fraud ring which involving a doctor, pharmacists, several city pharmacies, millions in fraudulent Medicaid billings and large monetary transfers to individuals in Pakistan.

Sixteen individuals and five corporations have been indicted in the ongoing investigation and a civil action has been filed against 20 individuals and entities freezing assets and seeking the recovery of more than $22 million…”

National Medicaid transport probed -- The Washington Times

Thu, 26 Oct 2006 20:11:48 -0700

National Medicaid transport probed — The Washington Times

“Since so much money is involved here, the federal government certainly has a very keen interest in how it is spent,” Donald White, spokesman for the HHS inspector general, said yesterday of the nationwide look at Medicaid transportation costs.

Federal Audit of Medicaid Transportation Costs- Kaiser network.org

Thu, 26 Oct 2006 19:44:30 -0700

Federal Audit of Medicaid Transportation Costs To Determine … - Kaiser network.org -
Federal Audit of Medicaid Transportation Costs To Determine …
Kaiser network.org, DC
… Health care consultant Robin Mathias said Medicaid programs can lose as much as 30% to 50% of nonemergency transportation spending to fraud and abuse, adding …
US probing Medicaid transportation Science Daily (press release)
US probing Medicaid transportation Market-Day.net

Medicaid fraud alleged - New York Daily News

Thu, 26 Oct 2006 20:15:09 -0700

Medicaid fraud alleged - New York Daily News -
Medicaid fraud alleged
New York Daily News, NY - 7 hours ago
… Dept. to investigate the home and the clinic for possible Medicaid fraud. … The Medicaid fraud units of both the Health Dept. and …

Medicaid billing fraud settled - Wyoming Tribune

Thu, 26 Oct 2006 20:21:18 -0700

Medicaid billing fraud settled - Wyoming Tribune -
Medicaid billing fraud settled
Wyoming Tribune, WY
… “Wyoming’s piece is part of a $25 million settlement to be split among the United States, 30 states and the District of Columbia.

The government charged Pediatrix improperly billed Medicaid for its services between January 1996 and December 1999.

Review of Medicaid Eligibility in New York State, (A-02-05-01028)

Thu, 26 Oct 2006 09:09:10 -0700

October 10, 2006

Complete Text of Report is available in PDF format (1.6 mb). Copies can also be obtained by contacting the Office of Public Affairs at 202-619-1343.

EXECUTIVE SUMMARY:

Our objective was to determine the extent to which the State agency made Medicaid payments on behalf of beneficiaries who did not meet Federal and State eligibility requirements. The State agency (1) made some Medicaid payments on behalf of beneficiaries who did not meet Federal and State eligibility requirements and (2) did not always adequately document eligibility determinations. Of the 200 payments in our statistical sample, 16 payments totaling $874 (Federal share) were unallowable because the beneficiaries were ineligible for Medicaid. In addition, for 58 sampled payments totaling $10,699 (Federal share), the case files did not contain all documentation supporting eligibility determinations as required. As a result, for the 6-month audit period from January 1 through June 30, 2005, we estimated that the State agency made 4,217,888 payments totaling $230,375,748 (Federal share) on behalf of ineligible beneficiaries. We also estimated that case file documentation did not adequately support eligibility determinations for an additional 15,289,843 payments totaling $2,820,569,979 (Federal share). We did not recommend recovery primarily because, under Federal laws and regulations, a disallowance of Federal payments for Medicaid eligibility errors can occur only if the errors are detected through a State’s Medicaid eligibility quality control program. We recommended that the State agency use the results of this review to help ensure compliance with Federal and State Medicaid eligibility requirements. Specifically, the State agency should (1) reemphasize to beneficiaries the need to provide accurate and timely information and (2) require its district office employees to verify eligibility information and maintain appropriate documentation in its case files.

To build a better fraud trap

Thu, 26 Oct 2006 20:23:06 -0700

To build a better fraud trap
Minnesota companies Ingenix and Fair Isaac are each working on technology to help identify false claims that contribute to skyrocketing health-insurance costs.

BY JULIE FORSTER
Pioneer Press

Ferreting out intentional crime from a legitimate mistake or simply a difference in opinion between a doctor and insurer is not always black and white. *Robin Mathias*, a health care fraud consultant based in Santa Rosa, Calif., noted that while it is cutting edge, the technology is not as clear-cut when used to find health care fraud as it is in finding fraud in the credit card industry.

Sebelius Says New Law Will Crack Down on Medicaid Fraud - Kansas City infoZine

Wed, 17 May 2006 11:41:38 -0700

States are enacting new laws to help fight Medicaid fraud.

Sebelius Says New Law Will Crack Down on Medicaid Fraud - Kansas City infoZine -

Medicaid fraud costs taxpayers money, and to crack down on this crime, Governor Kathleen Sebelius today signed a bill that expands the scope of the current fraud law.