July 01, 2022

Medicaid audit plan draws fire Maine groups oppose use of independent firm

Maine’s hospitals and doctors are gearing up to fight a state plan to root out any fraud and overbilling of Medicaid that occurred during the past five years.

The medical groups object to Department of Human Services Commissioner Kevin Concannon’s plan to offer a percentage of recovered money to an independent consulting firm that will be looking for Medicaid abuse.

“This has generated a firestorm of protest among Medicaid providers and people are very concerned,” said Gordon Smith, executive vice president of the Maine Medical Association. “It’s our highest [legislative] priority.

“It isn’t that we’re not in favor of rooting out fraud and abuse as the department is, this kind of work should be done,” Smith said. “But this kind of work should be done by state employees.”

The MMA is introducing a bill to stop the investigation by outsiders. Smith said that the more than 90 percent of doctors who accept Medicaid patients are already paid too little by Medicaid. An action like this would damage trust, he said.

“It’s the principle of the thing,” Smith said.

But Concannon dismisses the statements and said the MMA’s position that this is a top priority is “parochial,” because there are more important issues in health care.

“I know they don’t like it,” Concannon said. “I say, ‘Gee, if you’ve got nothing to hide what’s to worry here?’ ”

Eugene Gessow, director of DHS’ Bureau of Medical Services, said the MMA doesn’t understand that he will be in control of the whole process.

“What we’re looking at is back office support to support our front office decision-making,” Gessow said.

Under the plan, the consultant would analyze five years worth of billing data to look for patterns that could signal problems.

The department would analyze all of the work by the consultant and go after potential abuses only after Gessow’s approval.

“It will be based on our standards,” Gessow said.

The deal being offered Public Consulting Group would pay only a percentage of recovered money after the formal process was complete and the state had received its share of the money, Gessow said. About two-thirds of recovered money would go to the Federal Government.

Gessow said he is putting the final touches on the offer, which will be accepted or rejected by Public Consulting within a month. For its efforts, the consultant would be paid 25 percent of the state’s recovered money up to $5 million, 22 percent of recovery between $5 million and $10 million, and 20 percent of state recovered money thereafter.

Without the necessary staff and equipment on hand, the state could never go after these abuses that might recover several million a year, Gessow said.

The state’s regular recovery effort, through its surveillance and utilization review unit, amounted to $1.27 million in 2000, he said.

A final deal will be offered and could be accepted within a month, he said.

With the state already facing a shortfall of more than $200 million this year, the governor and Legislature are scrambling to find the means to plug the budget hole.

Concannon said any overbilling should be ferreted out. Recently, for instance, an investigation led to charges that McGovern’s Ambulance Service of Calais allegedly bilked Medicaid and Medicare for nearly $1 million over several years. That case is now in the courts.

DHS does not apologize for offering a percentage of recovered money to the consulting group. There was no appropriation in a law passed last year in the Legislature, so the commission payment proposal is appropriate, said David Winslow, a Department of Human Services spokesman.

While the Maine Hospital Association has not put the issue at the top of its agenda for the 120th Legislature, it is concerned, said Mary Mayhew, vice president for governmental affairs for the Maine Hospital Association.

In a letter to Concannon, MHA President Steven Michaud asked that the department be vigilant in overseeing the consulting firm’s actions.

“We have concerns that because this firm is inexperienced in audits such as this, complications or errors may result as the company gets up to speed,” he wrote. “We’re also concerned that because the firm will be paid on a contingency basis, it may be inappropriately aggressive in its methods.

“Maine’s hospitals have a long record of working effectively with the state on Medicaid accounting issues,” he wrote. “We routinely return overpayments and work together cooperatively with DHS to resolve any differences. It would be extremely unfortunate if this working relationship were undermined in any way by the state’s new recoupment process.”

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