Posted and filed under FWA.

Last week, Advize Health returned to Florida after fighting fraud in Baltimore during NAMPI 2016. This annual National Association for Medicaid Program Integrity took place from August 28-31st, and was held at the Baltimore Marriott Waterfront Hotel. This conference offered more than waterfront views and famous Baltimore cuisine. Jeanmarie Loria, Advize Health’s Managing Director and members of the Advize team immersed themselves in the world of Program Integrity in order to strengthen their fraud-busting skills and remain current on the latest industry trends. Fraud, waste, and abuse (FWA) continue to drive up healthcare costs for payers, providers, and patients alike – a trend that was addressed through the duration of the conference.

The NAMPI agenda was heavily populated with information on fraud in the healthcare space, and provided attendees with unique insights on the various channels fraudsters are exploiting with new and rising schemes. The emergence of fraud in a multitude of specialties was thoroughly covered, exposing areas of weakness that may have gone unnoticed the past. Some highlights from these fraud heavy sessions include a discussion on Health Technology. Recent events, including the massive breach at the hands of notorious hacker “The Dark Overlord” have done wonders in raising awareness about the needs of heightened cybersecurity when it comes to EHR‘s are other digital receptacles of PHI.

Hospice care, an area that unfortunately does not garner much attention, has been home to a rising number of fraud schemes in recent years. Hospice and palliative care centers become involved in fraud schemes when patients are diagnosed with exceptionally early, or even fake, diagnoses of terminal illnesses. Hospice has come under fire, falling at the hands of misleading marketing campaigns that suggest terminal illness is no longer a requirement for hospice-offered benefits. These seemingly small and isolated incidents have become larger issues, contributing to an already robust culture of fraud in the healthcare space. Other topics of interest included: skilled nursing facilities, where upcoding is on the rise thanks to the manipulation of RUGS, and prescription fraud that touts diabetes medicine as a weight loss supplement.

In between cracking crustacean shells and enjoying Baltimore’s finest crab and sea-food, Advize Health also managed to catch a session on PI Unit Organization. This session covered the basics of State Medicaid Program Integrity, as well as collaboration and stakeholders before delving into the hot button issue of FWA. Protecting public funds from FWA is an issue that needs to be addressed with its true severity in mind, and its approach can be no laughing matter. Protecting public funds requires the cooperation and collaboration of several departments and concepts: prevention, evaluation, enforcement, recovery of improper payments, and referral. When these measures all combine to achieve this noble common goal, funds are protected and compliance regulations are met.

Prevention involves the education of staff and the regulation of onsite activities that could compromise the integrity of the program, while detection involves intake units, data analytics, and preliminary investigations that can be used to detect red flags before they emerge. Program oversight ensures program security, and supports compliance – which contributes to the recoupment of funds and loss prevention. The demand for FWA prevention programs is steadily climbing, and the sessions presented at NAMPI not only educate, but inspire thought leaders to maintain the integrity of the business in a manner that is smart, efficient, and supportive off healthcare’s infrastructure.