Study finds $4.1 million in possible Medicaid fraud in Delaware

DOVER — A new report from an outside monitoring company has found $4.1 million worth of potential Medicaid fraud in Delaware.

Medicaid fraud can include billing the government for unnecessary procedures or care that was not actually rendered.

Ordered by the Legislature, the report was formulated by Health Integrity, which the Department of Health and Social Services commissioned to develop a program to oversee potential patient and provider misuse of services.

The company looked at areas such as dental services, lab visits and hospice care to find fraudulent activities, concluding approximately $4.1 million worth of transactions should be examined further due to possible misconduct.

The majority of those costs come from treatments billed as inpatient when they should have reported as outpatient, which is cheaper. Some 313 claims totaling about $2.5 million were reported, although Health Integrity cautioned it is not certain all are actually fraud.

“As this is an edit with further review needed, there is no guarantee that all of these claims will result in evidence of overpayment,” the company’s findings read.

About $1.1 million to be investigated further comes from dental crowns, which in Delaware are covered only if the procedure is medically necessary. The company singled out claims that did not have an X-ray done with them, as X-rays are one of the most common ways to determine if a crown is required. As they are not the only option to ascertain if a crown is needed, not all of the 1,215 payments are necessarily suspect.

Another $28,000 comes from 187 cases where a patient may have been improperly reported as new, while $27,000 worth of care is suspect due to 147 services having been conducted on teeth that had been previously reported as removed.

“While the identified dollars associated with this edit thus far are low, there is a risk of fraudulent billing that could be associated with this edit,” the findings state for both the new patient and removed teeth cases.

An additional $541,000 falls under other categories.

The company looked at data from March of 2012 to March of this year. It is set to present a more detailed report in September.

In February, the Legislature’s Joint Finance Committee criticized DHSS for the months-long delay in hiring a company to examine possible fraud and abuse. About 230,000 Delawareans are enrolled in the state’s Medicaid program.


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