Louisiana was recognized by the federal Centers for Medicare & Medicaid Services (CMS) for implementing best practices aimed at eliminating waste, fraud, and abuse in state Medicaid programs. Louisiana is one of only eight states to receive this honor.
Dr. Rebekah Gee, secretary of the Louisiana Department of Health, which administers the state’s Medicaid program, said this achievement highlights the outstanding diligence of the Medicaid program team to design systems to prevent and detect fraudulent activity.
“Preserving the integrity of this program is a top priority at the Louisiana Department of Health (LDH), and we are proud to share our innovative and creative practices with other states to further strengthen program integrity while eliminating waste, fraud and abuse,” said Gee.
CMS’s Medicaid Promising Practices in Program Integrity project supports states’ efforts to reduce improper Medicaid payments by sharing practices other states have found to be effective.
Louisiana was recognized for four best practices:
● The Special Investigation Unit Case Evaluation Review establishes review criteria to evaluate whether managed care organization (MCO) reporting of fraud investigations is accurate, complete and effective. Implementing this program has resulted in strengthened fraud reporting by MCOs and allows LDH to identify opportunities for further review.
● The Medicaid Fraud Control Unit (MFCU) received almost double the number of MCO fraud referrals in the 12 months after implementation of the MCO Fraud Referral Form and LDH Referral Feedback Form. The forms respectively establish standard reporting of confirmed fraud or abuse and a standard LDH assessment on quality and completeness of the plan’s referral.
● In the 12 months following implementation of the Provider Fraud Referral Form, MCOs submitted 173 notices of suspected fraud or abuse. This form facilitates the reporting of suspected fraud and abuse to LDH and MFCU. MCOs are required to report all suspected or confirmed fraud or abuse.
● The number of tips and complaints reported by MCOs has tripled since the introduction of MCO Tips Reports in 2015. These reports facilitate sharing all complaints of potential provider fraud, waste, or abuse reported to LDH Program Integrity and to each MCO. LDH compiles and shares among all plans monthly, since the providers could be participating in multiple statewide MCO networks.
Within LDH and its partner managed care organizations, there are multiple systems in place to detect and prevent fraud. These include the use of pattern matching algorithms and other analytics to look for potentially fraudulent billing practices.
Also, each managed care organization has its own program integrity unit that works with the department to share data and information that is critical to fraud prevention and identification.
The other states recognized by CMS were California, Idaho, Minnesota, Montana, Ohio, Oregon, and Wisconsin, making Louisiana the only Southern state to achieve such an honor.