PENNSYLVANIA NEEDS AN AUTOMATED SYSTEM TO DETECT MEDICAID FRAUD AND ABUSE

• NCJ Number: 67031
• Author(s): ANON
• Date Published: 1979
• Length: 27 pages
• Corporate Author: US Comptroller General
• Sale Source: Azimuth Inc.
• Publication Type: Program/Project Evaluation
• Language: English
• Country: United States of America
• Note: THERE IS A CHARGE FOR MORE THAN ONE COPY.

Annotation

FINDINGS AND RECOMMENDATIONS ARE REPORTED FROM A GENERAL ACCOUNTING OFFICE EVALUATION OF PENNSYLVANIA'S METHODS FOR CONTROLLING AND DETECTING MEDICAID FRAUD AND ABUSE.

Abstract

MEDICAID FRAUD AND ABUSE CAN GO UNDETECTED IN PENNSYLVANIA, PRIMARILY BECAUSE THE STATE DOES NOT HAVE AN AUTOMATED CLAIMS PROCESSING AND INFORMATION RETRIEVAL SYSTEM IN FULL OPERATION. MORE STATE FUNDS ARE NEEDED TO IMPLEMENT THE PLANNED MEDICAID MANAGEMENT INFORMATION SYSTEM (MMIS). IN ADDITION TO PROVIDING THE STATE WITH AN EFFECTIVE CLAIMS PROCESSING SYSTEM, MMIS CAN ANALYZE THE CLAIMS DATA BASE TO IDENTIFY POTENTIAL FRAUD AND ABUSE. FEDERAL AND STATE INVESTIGATIONS OF MEDICAID FRAUD HAVE INCREASED DURING THE PAST YEAR, BUT HAVE LED TO FEW PROSECUTIONS. THE PENNSYLVANIA MEDICAID FRAUD CONTROL UNIT ONLY RECENTLY TOOK STEPS TO COMPLY WITH A FEDERAL REQUIREMENT TO ASSURE REFERRAL OF CASES FOR PROSECUTION. THE DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE SHOULD REVIEW THE UNIT'S ACTION. PENNSYLVANIA RELIES ON CRIMINAL STATUTES ON WHICH TO BASE ITS PROSECUTION OF FRAUD CASES, SOME OF WHICH CALL FOR LESSER PENALTIES THAN DO THE FEDERAL MEDICAID FRAUD STATUTES. TO COMBAT MEDICAID FRAUD, PENNSYLVANIA SHOULD ESTABLISH PROVIDER AND RECIPIENT FRAUD STATUTES CONSISTENT WITH FEDERAL STATUTES. (AUTHOR ABSTRACT MODIFIED--RCB)