Welcome to the Pondera FraudCast, a weekly blog where we post information on fraud trends, lessons learned from client engagements, and observations from our investigators in the field. We hope you’ll check back often to stay current with our efforts to combat fraud, waste, and abuse in large government programs.
In a recent Texas senate hearing, it was revealed that in 2015, the state’s 22 Managed Care Organizations (MCOs) had recovered only $2.5 million of fraudulent payments out of $12.5 billion in claims. That’s about two-hundredths of a percent. Not one of the MCOs recovered even 1% of payments and most reported less than $20,000 in recoveries per full time investigative resource.
These numbers are stunningly low considering the actual amount of managed care fraud, estimated by the American Bar Association to be over $17.5 billion per year. There are dozens of ways to commit fraud in managed care programs including enrolling ineligible, deceased, or incarcerated individuals, collusion and kickback schemes among providers, and billing across MCOs.
In fact, many instances of managed care fraud can be even more insidious than the fraud found in fee-for-service programs. For example, rather than billing for unnecessary services which is common in fee-for service, fraudulent managed care providers are more apt to deny necessary procedures to increase their profits. They also recruit healthy members to bill capitation fees while incurring smaller expenses than those for less healthy members.
As states move more of their Medicaid populations into managed care, it is critical to not pass the responsibility of fraud detection to the MCOs. The current situation in Texas, whatever the causes, should not be tolerated. It is clear that not all MCOs will “play by the rules” and this will inevitably lead to higher capitation rates and less effective care. This is pretty ironic considering that lower costs and improved care were two of the main drivers behind moving to managed care in the first place.
A common topic on Pondera’s blog is the seemingly endless acceleration in the number of drug overdose deaths. And based on recently released data from the CDC, this will likely be a topic into the future as well. In fact, the CDC points out that drug overdose deaths nearly tripled between 1999 and 2014, and increased an additional 11.4% last year to 47,055.
Of particular concern to Pondera is the growth in opioid-related addictions which now account for 63% of drug overdose deaths. Opioids include heroin, prescription drugs like oxycodone and hydrocodone, and synthetic opioids like fentanyl. Each of these drugs, some legal, others illegal, can offer a similar high to those who use them without medical supervision. This is why you read stories of users who “graduate” from prescription medications to heroin when the prescription is no longer available or affordable to them.
Another tragic consequence of opioid abuse is the growing number of babies born with drug withdrawal systems. This problem is especially prevalent in rural areas of the country where 7 out of every 1,000 babies enter the world with drug withdrawals. This represents a 700% increase over the past decade.
So now that we agree that this is problem, what can we do about it? In my opinion, we can stem this dangerous tide through increased media coverage, more patient and doctor education, the use of less harmful drugs, and technology to track abuses. As patients, it is important to ask questions of your doctor, to safeguard pills at home, and to dispose of them safely. And as citizens, it is important to demand education for medical professionals and the use of technology to track illegal “pill mills” and imports from other countries.
It’s clear that curbing opioid abuse is going to require a difficult and sustained fight. However, I’m confident that by working together, we can make a difference.
As a company, Pondera is closely following the comments coming from the incoming administration about how they are approaching government efficiency and entitlement reform. Paul Ryan, in particular, has made several statements about the Affordable Care Act (Obamacare), Medicare, and Medicaid. This post provides some of our thoughts around how these changes may affect fraud, waste, and abuse.
While changes are clearly coming to Obamacare, this week Speaker Ryan also hinted at potential changes to Medicare and Medicaid. In Medicaid, where Pondera works with multiple states to detect fraud, Ryan hinted that the administration would consider offering tax credits in place of expanding the number of Medicaid recipients. This is necessary because Medicaid expansion, a byproduct of Obamacare, shares its fate with Obamacare.
While the tax credit idea is interesting, it is certainly not without its own problems. Tax credits, which unlike tax deductions offer dollar-for-dollar savings off bottom line taxes owed, are an attractive target for fraudsters. In fact, the Earned Income Tax Credit (EITC), which offers tax breaks to low income Americans, suffers from a 23.8% improper payment rate in 2016. This is one of the highest rates for any government program translating to $15.6 billion in waste.
On the surface, it seems the administration’s idea may shift much or all of the fraud problems in Medicaid expansion from health departments to state tax collection agencies. Here is one thing we can be sure of though: as long as there are large amounts of money in these programs, there will be bad actors who will attempt to defraud the system. And experience shows us that they will create innovative and technologically-advanced methods to support their efforts.
It’s only been a few hours since the election of Donald Trump, and we are already fielding questions about what this all means to Pondera. And while I must confess, like most Americans the election result was a bit of a surprise to me, we have been preparing for change no matter who won the election. This is because any change in administration leads to changes in priorities.
If I think back only a decade or so, active government program initiatives included Real ID laws for driver licenses, modernizing voter systems, and prison offender management systems. The Obama administration shifted a lot of focus and funding to Medicaid systems, insurance exchanges, and other health and human services programs.
What will the Trump administration mean to a fraud detection company like Pondera? While it’s still too early to tell, President-elect Trump has certainly provided some clues. For example, in one campaign speech he proposed funding his childcare initiatives by targeting fraud in state Unemployment Insurance Programs. And anyone who has been paying attention to the news recently could reasonably expect that voter fraud and the Affordable Care Act will receive some attention over the coming months.
Here is one thing that I know for certain. Come January, fraud will continue to be perpetrated against government programs no matter what party or which candidate is in charge. To fraudsters, large government programs are considered a target-rich environment too large to ignore.
While shopping for groceries this week, my wife turned from her cart when a man stumbled and fell in the aisle. Less than 30 seconds later, she noticed that her wallet was missing from her purse which was sitting in the cart. Total distance from her wallet: 5 feet.
Within 3 minutes, she’d called me and alerted the store about what had happened. Within 15 minutes, I’d blocked our ATM card, our credit card, and a specialty retailer card. Total Time: 18 minutes and 30 seconds.
What had the robbery netted? A $1,000 gift card purchased at a kiosk at a nearby retailer with our credit card. A second $1,000 gift card purchased at the same kiosk with our ATM card (I was under the mistaken impression that this would require the PIN number). And a $5,000 gift card purchased with the specialty retailer card. Total take: $7,000. In just 18 1/2 minutes.
Of course, the thieves also got away with about $150 in cash and my wife’s driver license. She was worried that we were going to be robbed that evening “because they now had our address” but I convinced her that “having our address” made us no more likely to be robbed. We also freeze our credit which offers us some protection from identity theft. So this gave us some comfort.
After this incident, I wondered just how much “old fashioned” credit card fraud still exists in the United States. As it turns out, quite a bit, as 23% of the $3 billion in annual credit card fraud is still the result of lost or stolen cards. I was surprised at this number given today’s more sophisticated identity theft and forgery schemes.
As often is the case with fraud though, the aftermath can be even more costly than the initial theft. Financially, even though we were not directly responsible for the fraudulent transactions, in the end, we pay through higher fees and rates. And of course, it’s very difficult to assign a cost to the trauma of being robbed at your neighborhood grocery store.
The lesson in all of this for me? While it’s important to protect your identity online, don’t forget that thieves still snatch wallets, look for credit card offers in your mailbox and trash, and call your home to try to trick or intimidate you into providing sensitive information.
Donald Trump recently announced plans for a new child care and paid family leave plan. While I will not be offering any opinions on the plan or on Donald Trump as a candidate, I was interested to see that the announcement sparked discussion of government fraud, waste, and abuse. In this case, the discussion surrounds the Unemployment Insurance (UI) program because Mr. Trump claims that he will reduce fraud in UI by over a billion dollars each year to help pay for his proposed child care plan.
Paymentaccuracy.gov, a government website devoted to providing information on payment inaccuracies, estimates a 10.7% improper payment rate in UI for 2016 resulting in $3.5 billion in erroneous payments. While a small amount of this actually represents underpayments, the majority of the $3.5 billion is waste. The trick, of course, is reducing fraud without delaying benefits to those who are eligible and without spending more money on improving the system than you actually save!
This is where things get interesting. The White House Office of Management and Budget claims that UI program integrity improvements, over the next 10 years, would result in just $150 million a year in savings, or just over 4% of the $3.5 billion. The Congressional Budget Office’s estimates are even worse. They estimate annual savings of $40 million at a cost of $17 million per year, for a net gain of just $23 million per year!
These dramatically different viewpoints between Mr. Trump and government regulators point out two problems when discussing government fraud, waste, and abuse. On the one hand, aspiring politicians and much of the public dramatically underestimate how difficult it can be to detect, investigate, and enforce fraud findings. On the other hand, many government agencies only report on the fraud they know about and estimate savings based on using traditional techniques against those unrealistically small numbers.
Here’s what I can tell you from our experience working in Unemployment Insurance. By combining modern detection techniques with cooperation between states and the federal government, we could net far greater savings than are estimated today. Whether or not other facets of Mr. Trump's program are viable is up to you, the voter, to decide. However, I think we can all agree that there are better uses for those funds than making payments to fraudsters.
On June 9th of this year, Mike Carroll, the Secretary of the Florida Department of Children and Families provided powerful testimony to the House Oversight and Government Reform Subcommittee on Government Operations. Secretary Carroll outlined some of the many successes Florida has achieved in fighting SNAP fraud. He also clearly articulated a point that we constantly stress here at Pondera. In his words…
“We are not talking about “mom and pop” storefront operations or cottage industries. We are talking about major criminal enterprises with ties to other serious and dangerous criminal activities including drug sales, prostitution and human trafficking.”
He went on to describe the SNAP program’s largest bust ever at a flea market in South Florida. Since 2011, the flea market had served 41,000 SNAP recipients and processed $89 million in transactions. Investigators found display stands using plastic fruit and vegetables, rotten produce, guns, and large amounts of cash at the retailers.
While 22 arrests have already been made, authorities still have a huge investigation in front of them. In addition, Florida is taking what they’ve learned and using it to identify other suspect locations.
This case, while large, is clearly not an isolated incident. Consider that even using the government’s own 3.7% improper payment rate translates to $2.6 billion per year in SNAP fraud and waste. Those numbers surely support a large number of organized schemes. So for those of you that think SNAP fraud is a “victimless crime”, it’s clearly time to reconsider your position.
I am often asked what motivated me to start Pondera. So… Here goes.
In 2011, after my previous company was acquired, a good friend working at Google asked me to visit their Mountain View campus. He was interested in learning how to embed Google products in large government programs like Medicaid, Unemployment Insurance, and eligibility systems.
Over the course of a couple of days, I was briefed on Google’s products and capabilities and I was struck by the massive computing power that their customers could literally “rent” as needed. Having spent over 20 years in technology, it was becoming clear to me that cloud computing was more than the latest tech buzzword. But it was during a discussion about the Google Prediction API though, that my imagination was really piqued.
With Prediction API, I realized, government organizations could analyze huge amounts of data to predict future events and identify data anomalies. All without ever buying a single piece of hardware or software. Thinking back to my time working on large government systems, I realized that this new technology had the potential to solve one of the problems that had always bothered me: fraud, waste, and abuse.
Over the years, I had worked on over 100 large government projects. And it had always amazed me that despite the fact that improper payments often exceeded 10% of program disbursements, most government bids had only a handful of requirements to address the problem. My government colleagues explained that they were under such pressure to deliver their services with such limited budgets that they simply could not invest appropriately in fraud detection.
Sitting in that room at Google headquarters, it was apparent to me that emerging technologies offered a new way to solve an old problem. One week later, I founded Pondera and set out to change the fraud detection market. Five years later, we’ve helped our clients prevent and collect hundreds of millions of dollars in improper payments. And we’re just getting started...
Fighting fraud is an interesting challenge. When an organization shuts down a fraud scheme, bad actors don’t suddenly become good citizens. Rather, they evolve. They evolve by designing and testing new methods that, when they succeed, are exploited until they too are detected and shut down. In fact, many of the more enterprising fraudsters proactively try out new methods to avoid any “breaks in revenue”. This constant game of “whack-a-mole” is well known to program integrity staffs.
This ever-changing nature of fraud schemes demands an ever-changing detection system. If an organization’s fraud detection methods look more or less the same as they did the year before, I can almost guarantee you that their fraud rates have returned to the levels prior to the introduction of the detection systems. Bad actors will simply find another way to conduct their business.
For these reasons, it is important to be nimble in fighting fraud. Complex technologies and massive data warehouses will lose effectiveness over time. If it takes a year to negotiate a change order, to deploy new technologies, or to integrate new data sources, literally billions of dollars in improper payments can be lost. The trick is to stay even with or just a “step” behind the bad actors, not miles behind.
While all state agencies want to choose the right partner to help them with their fraud detection efforts, I would challenge them to ask themselves the following questions: How easy is the company to work with? How willing will they be to incorporate new technologies (even if not their own)? How important is fighting government fraud to their company versus everything else they do? How passionate are they about the problem? Honest answers to these questions will reveal a lot about the future success of your efforts.
As a company that works with government clients, we spend a tremendous amount of time and money responding to Requests for Proposals (RFPs). We understand that governments use RFPs to ensure competitive bidding processes and to articulate their requirements. However, the process still causes enough angst for prospective bidders that, ironically, it often actually limits competition.
We wrote in a previous blog post about the lengthy RFP procurement cycles and their impacts on the final project. Today I’d like to discuss the formats of the RFPs themselves which often cause confusion, leading to large numbers of vendor questions, which in turn leads to delayed timelines and incorrectly submitted bids. I confess that I have never been on the “other side of the table” writing an RFP and I can only imagine how difficult it must be. But I still have one simple suggestion that I wish government agencies would take prior to releasing an RFP.
Before releasing an RFP to the vendor community, I suggest that government run an internal “mock” procurement: “release” the bid to a few agency employees and ask them to respond to it. They don’t have to provide actual answers, just an outline so they can make sure they understand what the RFP requires, where responses should go, how the format works, and other structural issues. It’s important that these people had nothing to do with the writing of the RFP document itself because then they’d naturally understand what they intended when they wrote it.
Commonly confusing issues we see in RFPs include where to place a Statement of Work (in tables or in text), repeated questions, seemingly mutually exclusive statements or requirements, and “thrown in” requirements that belong in other sections and break up the flow of the response.
I think government officials would be amazed at how much confusion and time they could take out of their procurements by performing this simple quality assurance exercise. This would also reduce the number of questions the state would have to respond to and provide more focus on issues of substance rather than administrative or formatting issues. Finally, it would lead to more uniformity of responses allowing governments to evaluate responses for their merit rather than having to search for answers to their requirements.