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Pondera FraudCast

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.

Online access to groceries for SNAP recipients

Online access to groceries for SNAP recipients

The USDA recently announced a pilot program, starting this August, to offer online access to groceries for Supplemental Nutrition Assistance Program (SNAP) recipients in seven states. Groceries will be delivered to the recipients’ homes by seven participating retailers including familiar names such as Amazon, Safeway, and Shoprite.

For many SNAP participants, this is both a tremendous convenience (saving them time) and a potential necessity (providing access to healthy foods in rural and urban “food deserts”). In fact, America’s poor have higher access to the Internet than they do to cars: 88% to 79.6%. And no one can argue that time spent with family, working, or seeking work is more valuable than time spent commuting to and shopping in grocery stores.

Of course, online transactions often lead to more opportunities for fraud. And for their part, the USDA is mandating stricter controls than those required for non-SNAP transactions, including the use of a secure PIN number on all SNAP transactions. They have also provided funding in recent years to help states address benefit card trafficking problems.

It is also known that when large sums of money are distributed through online transactions, bad actors will innovate new ways to defraud the system. In 2014, while the improper payment rate in SNAP was relatively low at 3.66%, this still represented over $2.5 billion. Perhaps more concerning is that for 2015, after the USDA worked with all 50 states to assess their payment accuracy rates, they were not able to provide an overall improper payment rate for the SNAP program because data from 42 of the 53 reporting agencies could not be validated.

In many ways, this situation encapsulates the challenges facing government organizations. While their main directive is to provide important services to citizens – which I believe includes online access to nutritious foods—they also must protect the taxpayers’ money and make sure benefits go to those who are qualified to receive them. We wish the USDA luck with this new pilot and stand ready to assist our state government clients in their program integrity efforts.
Managed Care Fraud

Managed Care Fraud

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.

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Pondera leverages advanced prediction algorithms and the power of cloud computing to combat fraud, waste, and abuse in government programs.



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