The State of Alabama Medicaid Agency has intensified its payment accuracy efforts by embarking on a two-year effort to review claims and identify any funds owed to the state.
The agency is working with Eden Prairie, Minn.-based Ingenix on a focused post-payment review of claims filed for the past two years by all Alabama-based healthcare provider groups, including hospitals, physicians, dentists, pharmacies, durable medical equipment companies, and home healthcare providers.
Under terms of the agreement, rather than receiving a flat contract fee, Ingenix will be paid a percentage of any incorrect payments identified and recovered.
According to Alabama Medicaid commissioner Carol Steckel, Ingenix will provide the agency with fraud, waste, abuse, and overpayment identification and collection tools and services, such as data mining, analytics, and detection algorithms.
"The goal of this agency is to make sure every public dollar is properly spent to improve the health of the people of Alabama, and to achieve that, we need to continuously seek ways to strengthen our program integrity and fraud-and-abuse prevention efforts," said Steckel, who also serves as chairperson of the National Association of State Medicaid Directors. "A contingency-based contract ensures that Alabama taxpayers are only paying for results."
The Alabama Medicaid Agency manages and administers the state's Medicaid program. The state's Medicaid program assists nearly 1 million eligible recipients annually, or about 20 percent of Alabama's population.
Steckel said the agreement with Ingenix would bolster Alabama Medicaid's comprehensive Program Integrity initiative, which includes the following components:
- a review of the list of sanctioned individuals to ensure that they are not working in any capacity for an entity that receives payments from Medicaid or Medicare
- a more rigorous review of any provider enrollment application in which the applicant has previously been sanctioned or suspended
- a requirement that Medicaid beneficiaries who have their eligibility reinstated after being suspended from the Medicaid program for drug-related fraud, abuse, or misuse of benefits be placed in the restriction program and have their utilization of benefits monitored for one year
- a review of new applications of durable medical equipment providers prior to enrollment to ensure they have a legitimate office and office staff
In fiscal year 2009, Alabama Medicaid reviewed 77 medical providers and 413 pharmacies, resulting in approximately $1.3 million in recoveries and nearly $4 million in cost avoidance. More than 100 beneficiaries were suspended from Medicaid for abuse or misuse of the program and nearly 700 were restricted or "locked in" to one doctor and one drug store to prevent potential abuse.
Alabama's quality-control rate, which measures the accuracy of the agency's eligibility determination process, consistently out-performs the national average of three percent, Steckel said. The agency's most recent error rate was only one-half of one percent for the year.