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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.

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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