As global government spending on Health and Human Services rises, interest in program integrity has also increased.
A recent news article out of North Carolina shows some real progress. That state is addressing inappropriate charges to its Medicaid program. Medicaid pays for the health care of millions of lower income and special needs Americans. According to the article, the State Attorney General won 22 criminal convictions and 18 civil settlements against various healthcare providers in the last fiscal year. These resulted in a recovery of $49 million.
In addition, North Carolina drove a 99% reduction in payments to one set of outpatient behavioral health providers. 37 providers were placed under prepayment review due to unusual billing patterns. These patterns, spotted with IBM software, indicated that the providers were abusing the Medicaid system. Claims to the State had been $19.2 million in six months prior to the additional reviews. After six months in prepayment review, billings from these 37 providers had fallen to $138,000 -- a $19 million reduction.
In total -- the article mentions nearly $70M of recoveries and avoided payments. This has been a stunning achievement for the State and a wakeup call for those looking to cheat taxpayers. Leadership, effective program execution, and analytics were critical to success.
Over the next several months, I’ll be writing a bit more about Program Integrity in Health and Human Services. Send me a note or give me a call if there’s a topic you’d like me to address, or if you have a question about how IBM’s solutions can help address these issues.