States are applying technology in their investigations of Medicaid home health providers — particularly using data mining to swiftly locate claims with similar features to past examples of fraud, waste and abuse.
The Office of Inspector General (OIG) for Texas Health and Human Services announced last week that it had opened “full-scale investigations” of two home health agencies following a review of documents and evidence collected during a preliminary review of the providers’ Medicaid reimbursement filings.
“The providers were identified during a fraud detection operation conducted in the first quarter of fiscal year 2023 that used an algorithm to uncover potentially fraudulent billing practices previously observed among home health providers,” according to a release from the state OIG on May 23.
The full-scale investigation will allow the OIG to take a closer look at patterns within the providers’ billing and medical records, including additional interviews and reviews of a more extensive set of client medical records, according to the release.
“I have been involved in several Medicaid fraud cases lately, but I am not sure any of them were the results of a data analysis,” says Robert Markette, an attorney with Hall, Render, Killian, heath & Lyman in Indianapolis, Ind. “To be honest, it was just a matter of time before state’s started doing data analysis akin to what CMS and OIG are doing.”
Upon enrolling in Medicaid, providers are required to maintain complete and thorough medical records that show the necessity of services and information supporting that the procedure was administered correctly, the OIG notes.
“The preliminary review of documents from the two providers revealed that key required items were missing from clients’ medical records, including physician orders, progress notes, assessments, reassessments, and care plans,” according to the release.