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Alaska Ramps Up its Fraud Fight

“The cooperation has been fantastic,” Peterson said.

The focus on to bringing cases, with partners’ help, reflects the state’s push to ensure limited resources are carefully leveraged.

“We can’t have people billing fraudulently taking money from people who need services,” Keilman-Cruz said.

Peterson, who transferred to the position about a year ago from fish and game prosecutions, said cases do more than correct an individual wrong – they deter others from stepping out of line.

One of the first cases he brought was against a taxi driver who charged for four rides when he’d provided two. The message to other taxi drivers was loud and clear: The state is willing to prosecute fraud.

That willingness extends to all segments of the home health industry, including personal care and home and community based waiver services.

Prosecutions can lead to serious consequences for any provider – such as jail time, fines, the loss of an operating license or the ability to bill Medicaid.

As word of the prosecutions spread, Peterson said he’s getting more referrals from other state and federal agencies — and from providers.

“We’re having a lot of individuals step forward,” Peterson said, which has helped with a number of prosecutions.

SDS will also change policy as needed to make billing requirements clear — such as revising the PCA Level of Service effective date.

“That will make it easier for me to prosecute,” Peterson said, “and ultimately deter fraud.”

Alaska’s hotline to report Medicaid fraud is 907-269-6279.

There’s also an online form for reporting fraud or elder abuse on the state Medicaid Fraud Control Unit webpage, Peterson pointed out. “You don’t have to call and talk to someone.”

Common problems providers can watch for

SDS Quality Assurance Chief Lynne Keilman-Cruz and state Assistant Attorney General Andrew Peterson talked about the most common problems they see, and gave these tips for avoiding trouble:

Backdating: “We find people are backdating services, which is never OK,” said Keilman-Cruz.

If a personal care assistant only wrote down 14 hours of services on their timesheet, the agency can only bill SDS for 14 hours, even if the client was approved for 22 hours.

Lack of verification: One of the most common mistakes is billing without reviewing timesheets to verify that services have been provided and hours are correct.

“An agency will bill for the max number of hours, but you look at the timesheet and see fewer hours – turns out the person was in the hospital for a few days,” Peterson said.

Agencies may be small and get overwhelmed if a minor emergency comes up, or so big or compartmentalized that the person doing the billing doesn’t know exactly what services clients are getting.

“It’s a beast,” Keilman-Cruz acknowledged. “There are a lot of moving parts.”

The department is happy to work with agencies to help them get it right, through technical assistance and audit corrections, Keilman-Cruz said, but also expects agencies to fulfill their obligations.

“You should never be submitting a bill to us when you haven’t vetted that services actually happened,” Keilman-Cruz said. After all, a big chunk of direct-service Medicaid payments is intended to cover indirect costs, including careful administration. “That’s an expectation we’ll be coming down hard on in the future.”

Lack of employee training: Employers can avoid problems by making sure that employees follow through on basic requirements. Three common issues: Employees must maintain records with time in, time out using a.m. and p.m., date of service, signatures and service notes for every time-based billing code. They need to know never to bill for services provided out of the country. They also need to know that they can’t have someone else provide care in their place then submit hours as if they had provided the services. Any “back up” PCAs must be enrolled, hired, have a valid criminal history check in place, and submit billings using their own number.

“A little advance training can protect the provider agency from being on the hook,” Peterson said.

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