Combatting Medicaid Fraud: Insights from Recent Oversight Meeting
During a recent meeting, the Medicaid Oversight and Advisory Board focused on updates related to Medicaid fraud and abuse control. Presentations were given by Rewa Zakharia, head of the Criminal Division at the Kentucky Attorney General’s Office, and Matt Kleinert, Executive Director of the Office of Medicaid Fraud and Abuse Control. These discussions emphasize the ongoing efforts to enhance regulatory compliance within the insurance industry.
The session highlighted that there are 53 Medicaid fraud control units operating under both state and federal frameworks. Kleinert addressed the pervasive issue of fraudulent activities, with a specific focus on behavioral health services and Medicaid waiver programs in Kentucky. The challenges in risk management were underscored by instances of family members submitting duplicative time sheets or reporting participant-directed services while being employed full-time elsewhere.
Addressing Fraudulent Billing Practices
The board also tackled fraudulent practices in medically assisted treatments and improper billing for unnecessary prescriptions. The Centers for Medicare & Medicaid Services (CMS) estimated in late 2024 that up to five percent of Medicaid payments could be classified as improper. This highlights the importance of strong regulatory compliance and fraud prevention measures within payer systems.
Senator Karen Berg emphasized the need for increased scrutiny as home-based Medicaid services expand, highlighting potential risks such as abuse and neglect. Senator Danny Carroll queried the measures managed care organizations (MCOs) take when fraud arises. Kleinert explained that fraud allegations are evaluated by the Inspector General's Division of Audits and Investigations, with credible cases referred for further investigation.
Representative Wade Williams inquired about criminal referrals, to which Kleinert responded that 58 hotline reports had been received, with six cases opened following MCO referrals. The meeting underscores the commitment to safeguarding regulatory standards and maintaining robust oversight within the Medicaid system and broader insurance sector.