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Preventing Fraud

Protect your agency’s resources: The key to detecting and preventing Medicaid fraud

· 5 minute read

· 5 minute read

If you’re involved in the management or the investigative function of a state agency overseeing Medicaid benefits, your detection work has become more challenging than ever in recent months. Given all the stresses of the pandemic period, that’s saying a great deal.

One of the chief reasons why that happened — is the closing this past spring of the Medicaid enrollment program created by the Families First Coronavirus Response Act (FFCRA). As of April 1, states began terminating Medicaid coverage for people who’d been enrolled via the FFCRA.

In the past several months, many of those “disenrollees” have been seeking to re-enroll. If your agency is like those in most states, the surge in new Medicaid applications has put additional strain on your already under-resourced agency. It’s essential to verify the identities of all these applicants – even if they had been verified in the past – to detect and prevent any fraudulent Medicaid claims.

And as you also know very well, the process of identity verification is time-consuming. And time is one of the key resources in short supply at most state agencies. Many also are having to deal with shortages in staffing. In some cases, that’s because of retirements and a shrinking talent pool. In others, it’s simply a lack of sufficient funding. In many cases, it’s both.

Fraudsters aren’t making the task of identity verification any easier. They’ve learned new tricks (most of them digitally based) to fool overworked investigative staff. One worry that has recently begun to trouble many agency leaders’ minds: the use of AI to create false identities and communications to illicitly access Medicaid benefits. Meanwhile, you and your colleagues have the added, ongoing burden of keeping on top of changing regulations.

With state agencies dealing with limited resources, the increased sophistication of fraudulent activity, and a massive wave of new enrollments, how can potential Medicaid fraud be detected?

Insights from colleagues

Again, your agency is by no means alone in the fight against Medicaid fraud. Each year, the Thomson Reuters Institute surveys state and local government managers and employees to assess whether they have the tools and resources sufficient to prevent, detect, and investigate fraud, waste, and abuse in the government benefits programs they oversee. The institute’s ”2023 Government Fraud, Waste & Abuse Report” finds that front-line government employees, which include directors, managers, administrators, and investigators, believe they’ve made progress in the fight against fraud. But they’re still struggling with numerous challenges.

This year’s study found that 59% of those surveyed are confident that they have the resources necessary to fight fraud, waste, abuse, but that level of confidence is down from 72% in 2022. As the report notes, one reason for this decline in confidence may be that fraudulent activity hasn’t declined, even with the pandemic’s fading.

The report also reveals that agency leaders are experiencing increasingly sophisticated methods of fraud, beyond traditional forms of fraud such as forged documents, false claims, and stolen identities. More than half (55%) of this year’s respondents believe overall fraud activity will continue to increase over the next two years, and that the number of in-depth investigations requiring additional resources won’t be decreasing anytime soon.

Given all this, what are the best strategies to meet the many challenges of identity verification in the current environment state agencies are having to master? How can you and your agency conduct this crucial work while conserving your resources? What do you need right now?

Speed is of the essence

Most importantly, you need to get Medicaid benefits to those who truly deserve (and need) them. That’s your agency’s mission, after all. What’s more, the federal Medicaid program can’t afford much fraud, waste, and abuse. And it’s a lot harder to recover stolen funds than to prevent them from being fraudulently purloined in the first place.

All this requires speed: the capability to verify identities quickly and accurately.

One weapon to consider in the fight against fraud is Thomson Reuters CLEAR, a cloud-based public records application that quickly pulls together and analyzes thousands of local, state, and federal data sets. It leverages digital technology to gather that critical identity data in a customizable dashboard. The user-friendly platform allows agencies to quickly search across thousands of data sets, connecting to live-feed data including real-time records, phone numbers, addresses, Social Security numbers, and the names and locations of relatives. It also displays the data sources it accesses so that you and your staff can ascertain that you have the most current and accurate identity information.

To gain deeper insights into detecting and preventing Medicaid fraud, download the Thomson Reuters Institute’s recent study.

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State Medicaid agencies: New challenges in the battle against fraud

State Medicaid agencies: New challenges in the battle against fraud

Agencies are exploring forward-thinking approaches to make sure those truly in need of Medicaid benefits receive them

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