Always Reppin’ – Region IV

Ann Kaperak (FL)

A Natural Disaster Drives Fraud Detection

As June 1, 2022, approached, many states in Region IV started their processes to ready for hurricane
season. Of the eight states in the region, only two do not have coastline, however upon the author of
this article’s research, it was found that even Kentucky and Tennessee have both felt the impact of
hurricanes at some point in the last 15 years. If we broaden even further, to natural disasters as the
subject of this article indicates, we can include tornadoes, floods, fires, and maybe even a snowstorm or
two.

You may wonder why this is important to those of us in the world of Medicaid Program Integrity. There
are so many ways this impacts our programs and the way potential fraud schemes come forward during
these times. And, for those of you who are in other areas of the country, stay with us, this applies to
blizzards, tsunamis, tropical storms, volcanoes, dust storms, earthquakes, hailstorms, sinkholes, wildfires,
ice storms, solar flares, and anything else you can think of. In many states one of the first things to
happen is the Governor declares a state of emergency. That allows for certain restrictions to be
loosened, including those related to health care.

When in a state of emergency to a natural disaster, it can be for a finite period of time, or for an
unknown period of time, depending on what the issue is. It can apply to certain areas of the state or the
whole state. What is important here, is to track the changes in policy your Medicaid agency and
Medicaid health plans (MCOs, CCOs, ACOs, etc.) make, what time frames the changes apply to, and
what areas of the state they apply. Additionally, it is recommended that we track what areas are
impacted by closures and when closures are happening. Otherwise, you may not be able to hold
providers or recipients accountable in the future as it is often hard to track down that information later.
Now on to the why this matters to those of us in Program Integrity. This is prime for fraud. Limits are
lifted, changes are made to policies for short periods of time. Fraudsters don’t expect that insurance
companies keep up with these short-term changes and just let the money float away, it’s a cost of doing
business. It does not have to be a cost of doing business though.

If your data and audit individuals work together to keep track of the days and times of these
occurrences, you can combat this issue together. Our recommendation is to make it a project 18 months
to 2 years later once the claims have cleared and any adjustment periods are over. Also, we suggest,
work with your health plans. Make sure provider notices and policies are kept. Do your reviews. Make
appropriate referrals and recoup if able. The providers will not expect this to happen. They will not be
able to produce legitimate records for dates they were closed. Do not be hesitant to make calls to
recipients. You may find that recipients will have been more concerned about the natural disaster
looming, than the therapy service they were scheduled to have and were trying to get out of town or be
prepared.

These are just a few suggestions for a way to handle a different type of project. One that can be
repetitive but different each time as well. Also, a project that unfortunately, Region IV would be happy to
speak with you about. We hope everyone has a great summer with few storms and we look forward to
seeing everyone in Baltimore in August.