April 8, 2010
OHCA Contact: Jo Kilgore, Public Information Manager, (405) 522-7474.
OHCA Program Integrity Division Ensures Quality Program
OKLAHOMA CITY – Provider audits are one of the tools the Oklahoma Health Care Authority uses in it’s program integrity efforts to make sure state and federal tax dollars are being used correctly in the state’s SoonerCare (Oklahoma Medicaid) program.
Deputy Chief Executive Officer Cindy Roberts who leads the agency’s Policy, Planning and Integrity Division presented the OHCA Board with an update of their efforts during the board’s meeting April 8. According to Roberts, in 2009 approximately 5 percent of the estimated 28,000 SoonerCare providers had some level of audit or review performed.
The reviews, she said, are initiated because of some type of risk analysis such as peer-to-peer comparisons, referrals or data mining. Federal regulations require each Medicaid state agency to have an automated claims processing and retrieval system that can be used to detect post-payment errors. These systems, known as Medicaid Management Information Systems contain subsystems which compare and contrast SoonerCare claims activity by provider in comparison to their peers. The system also allows the program integrity division to perform comprehensive data mining of claims history.
“The extent of these audits or reviews may vary, from the validation of a single claim line to a representative sample of a provider’s SoonerCare services over a certain time period to a 100 percent review of a specific service billed by a provider,” Roberts noted.
For the first three quarters of state fiscal year 2010, OHCA closed 88 audits involving 1,155 providers. The majority of those audits, 73 percent, were the result of data-mining and peer-to-peer comparisons. The audits resulted in the recovery of $14.7 million in state and federal funds. The recovery represents .4 percent of the agency’s total program expenditures of $3.4 billion for the first three quarters of 2010.The federal share of any overpayment must be returned to the agency’s federal partner, the Centers for Medicare & Medicaid Services.
“It is interesting to note that these recoveries represent only .4 percent of the total program spending for the same time period,” Roberts said. “We have found that errors are far more common than activities that are specifically fraudulent or abusive.”
If fraud is suspected, the case is turned over to the Oklahoma Attorney General’s Medicaid Fraud Control Unit for further investigation. The OHCA also regularly reviews its policy and educates providers to try to avoid overpayments.