The $590 billion Medicaid program is exceptionally complex.  Medicaid’s massive size, astonishing complexity, varied roles, rapidity of change, and slim administrative resources all combine to make it a prime target for criminals. Meanwhile, providers – the vast majority of whom are honest – may incorrectly bill Medicaid or get reimbursed by Medicaid when a third party, such as a private health insurer or Medicare, should have paid instead.  To ensure Medicaid program integrity, we must combat a range of problems – from erroneous claims and unintentional payment errors to gaming of coverage and reimbursement policies and criminal activity.

New Episode of MediStrategy Podcast Discusses How to Combat Medicaid Fraud and Prevent Overpayments:

In a new episode of the MediStrategy podcast, hear from the industry leader in leveraging data, advanced analytics, and programmatic expertise to recover and prevent overpayments, detect fraudulent behavior, and ensure that Medicaid is the ‘payer of last resort.’

Today’s guest is Bill Lucia, Chairman and CEO of HMS Holdings, the nation’s largest and most successful company dedicated to providing the broadest range of healthcare cost containment solutions to help purchasers, plans, and at-risk providers improve performance. HMS works with over 45 state Medicaid programs, some 250 health plans, Medicare, large employers, and provider organizations to help contain costs and protect our nation’s healthcare system from waste, fraud, and abuse. Bill Lucia joined HMS in 1996, becoming chairman, president, and CEO in 2009.

In an in-depth conversation with Kip Piper, Bill Lucia shares insights about HMS’s pioneering and rapidly expanding work in the areas of health care fraud detection, overpayment recovery, and coordination of benefits and about HMS’ keen money-saving recommendations for Medicaid reform.

“Fighting health care fraud is like playing Whac-A-Mole.”
Bill Lucia, Chairman and CEO of HMS

Listen to this Episode Now:

Topics Covered in Medicaid Program Integrity and Cost Containment:

The topics covered in this episode of MediStrategy include:

  • The mission of ensuring the integrity of nation’s healthcare system by reducing costs and removing fraud, waste, and abuse.
  • The complex nature of the Medicaid system:
    • $590 billion in expenditures in 2017
    • Over 1 in 4 Americans enrolled in either Medicaid or CHIP (77 million in Medicaid and 6 million in CHIP)
    • Covers more types of services and providers than Medicare or any private insurer
    • Serves the most clinically and demographically diverse and most vulnerable, highest cost populations
    • Constantly changing
  • How HMS works to ensure program integrity in Medicaid:
    • Verify that claims paid by appropriate party (coordination of benefits or what in Medicaid is more often called third-party liability)
    • Confirm that claims are paid accurately (billed appropriately, only for medically necessary services, no errors related to policy)
  • How technology, know-how, and analytics are used to:
    • Identify providers with a propensity for incorrect billing
    • Recognize program rules that cause errors
    • Anticipate potentially fraudulent activity
  • How pattern recognition is used to detect inaccuracies and fraud in claims:
    • Unintentional errors in billings to Medicaid and commercial health plans)
    • Fraud such as billing in excess of 24 hours/day, 230 days/year
  • The significant return on investment from HMS program integrity work:
    • Over $1B in taxpayer dollars recovered annually
    • Far more saved through cost avoidance
    • 90% of their work is done on contingency
    • Average return on investment (ROI) is 15:1
    • One state reported 900% ROI
  • How to make the case for preventative measures (vs. recovery dollars):
    • States always looking to rein in costs and balance budget
    • Keeps the state in compliance
    • Benefits constituents who might not have healthcare otherwise
  • How HMS has built the industry standard with regard to coordination of benefits:
    • Feed eligibility data to established database
    • Identify beneficiaries with third party coverage (10%-13% of Medicaid enrollees also have private coverage)
    • Ensure that Medicaid is the ‘payer of last resort’
  • How to leverage advanced analytics:
    • Employ visual and geospatial analysis to identify fraud
    • Track members with chronic conditions (23% of members incur 90% of the costs)
  • HMS policy recommendations to Congress and States:
    • Use third parties to ensure Medicaid is ‘payer of last resort’
    • Incentivize states to improve oversight
    • Leverage premium assistance programs
    • Expand the use of data aggregation
    • Simplify the system to reduce errors

Learn More:

To learn more, visit HMS on the web at and follow them on Twitter @hmshealthcare and Facebook.

The HMS report on Effective Cost Management for Medicaid, with a series of recommendations for Congress and States, is available here (free PDF).

Listen and Subscribe to MediStrategy Podcast:

The MediStrategy podcast offers informative interviews with healthcare leaders and insights on hot business and policy issues in Medicare, Medicaid, and health reform.  Health executives, policymakers, entrepreneurs, authors, and other influencers share challenges and opportunities in America’s rapidly changing $3.2 trillion health care system.  MediStrategy is hosted by Kip Piper and offered free as a public service.

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