Modivcare SIU: Disrupting healthcare fraud, waste and abuse

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By Jody Kepler

Fraud, waste and abuse (FWA) in healthcare is, unfortunately, an everyday occurrence. Bad actors cost our healthcare system billions of dollars every year according to the U.S. Department of Justice.

The U.S. Government Accountability Office defines fraud, waste and abuse as:

  • Fraud is attempting to obtain something of value through willful misrepresentation
  • Waste is squandering money or resources, even if not explicitly illegal
  • Abuse is behaving improperly or unreasonably, or misusing one’s position or authority

You’ve likely read about healthcare organizations, hospitals, physicians and other groups who participate in government healthcare programs paying fines to the federal government to resolve FWA cases. A recent case found a Florida telemedicine company submitted more than $784 million in false and fraudulent Medicare claims.  Certain compounding pharmacies were found guilty of fraud for selling ointment to veterans who did not need it. These are just a few examples of the ways the federal government and health plans can lose money due to the actions of bad actors.

As a provider of supportive care services to health plans and federal and state governments, Medicare has a responsibility to ensure that the funds entrusted to us are spent correctly.

As part of that obligation, Modivcare has implemented programs and processes to identify, eliminate and act on FWA. To accomplish that, we built a unique team, the Special Investigations Unit, whose mission is to identify these activities, mitigate existing FWA, prevent them from occurring in the future and report to the authorities.

Modivcare’s SIU

Modivcare’s Special Investigation Unit works to ensure that government and health plan funding is preserved for those who need it: the members we serve. By regularly reviewing and auditing transportation provider (TP) charges, trip data, and investigating tips, Modivcare can help members by helping to hold dishonest providers accountable.

Most TPs and members, of course, don’t misuse the system. They report mileage correctly and use NEMT as it was intended by those offering the service.

When TPs abuse NEMT it can surface in one or more ways:

  • Excessive mileage claims
  • Driver/member collusion
  • Non-credentialed drivers who shouldn’t be transporting and charging for member trips
  • Drivers claiming more trips a day than can be provided Claiming a level of service that was not provided

In addition to this type of FWA, we sometimes face issues that originate with members:

  • Overstating mileage: Submit mileage reimbursement claims for more miles than driven. This is often accomplished by claiming a fictitious residential address that is further from the appointment than the member’s actual starting address
  • Overstating trip frequency: Claim a greater number of appointments than attended
  • Double-dipping: Multiple covered beneficiaries who drive together submit separate mileage reimbursement claims

Just as important as acting on intentional FWA is a team’s ability to investigate claims that, at first glance, might “look” like FWA but aren’t. No NEMT provider is perfect and billing errors or misunderstandings do occur.

We make sure to understand and investigate each issue before making a judgment. Many times, members need an advocate, and we help in these cases to make sure that trips do occur as scheduled. Some members, for instance, live in rural areas distant from healthcare providers, so it’s important to understand how this will affect the TP or mileage reimbursement.

Whether a TP or member participates in FWA, Modivcare may implement one or more corrective actions. Depending on the type and severity of the action, we may provide education, attempt to collect the erroneously issued funds or refer the case to our clients’ enforcement units.

Holding bad actors accountable

We work diligently with our health plan customers to keep bad actors, whether TPs or members, from exploiting the system. By working together, we can quickly identify and mitigate phony charges that negatively impact healthcare at-large as well as the TPs and members who use the system as it was designed. It's everybody’s responsibility to preserve the integrity of the NEMT healthcare benefit for TPs and members alike.

No matter how or when FWA occurs, all healthcare organizations must maintain a team of professionals with the ability to not only understand how it impacts the NEMT company, the health plan and healthcare, but also how intense scrutiny of existing data can combat future misuse.

Jody Kepler is Chief Compliance Officer at Modivcare.

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