Recently, Advize Health was involved in a matter pertaining to some medical record audits and investigations that were ongoing with a Social Adult Day Care (SADC), located on the West Coast.  For a five year period, this SADC was the subject of audits, investigations and referrals made by the state Medicaid agency to the Medicaid Fraud Control Unit (MFCU) in that state. 

The MFCU is the state counterpart to HHS-OIG, and is funded, in part with monies from the U.S. Department of Health & Human Services (HHS).  In each instance of a referral made by the state agency to MFCU, the MFCU declined to prosecute and found no issues of fraud.  We have been working with the SADC to establish some compliance benchmarking, including some proactive audits and reviews to ensure that compliance continues going forward. 

In the course of working with the SADC, we learned that the state agency recently, scheduled an onsite audit of the SADC records.  On the day the investigators were to show up, none arrived.  The owner of the SADC learned that the investigators had gone to the wrong location. 

This is the first misstep the agency had, albeit, not a disaster in itself. 

The problem, however, was that during the course of the past five years, where requests for documentation, other audits and countless hours of defending the facility, the owner learned that the investigators had, for the five years, been conducting surveillance on the facility.  In conducting their surveillance, the investigators noted that the claims being submitted for payment simply did not match the surveilled volume of Medicaid members that were attending the location under surveillance. 

In the second misstep, it turns out the investigators had, all along, been surveilling the wrong location; the same wrong location where they went to do the onsite for records. 

When I was told this, I had a huge jaw drop.  As a former OIG Special Agent, I conducted many hours of physical surveillance of people and locations.  The OIG utilizes some very modern surveillance equipment that is part of the investigative arsenal.  Being in the right place at the right time, is essential as an investigative step in any matter.  Going to the wrong place multiple times, and surveilling the wrong location, is just poor investigative work. 

To make matters worse, the fact that referrals were made to the MFCU for criminal investigation and prosecution, is something that is unbelievable.  As a staunch supporter of law enforcement, and of those working tirelessly to ferret out fraud, waste and abuse in healthcare, the resources spent on what amounted to just poor and sloppy work is more indicative of the inability of the law enforcement community to keep their fingers in the dike. 

I am not here to espouse that SADC do not have their fair share of FWA.  It is more about the allocation of resources, in that some solid preliminary and proper investigative work on the front end would have saved the SADC, the investigating agency and the MFCU a lot of time, energy, and most importantly, money. 

The SADC had a primary and a secondary location, with the primary location being where most of the Medicaid members went.  A quick review of records would have identified the various locations, which would have then sent investigators on the correct path.  You go to one location and it is not buzzing with activity, and you go to the other location, and alas!!! 

Would the audits and reviews continued? Possibly.  We will never really know the answer to that.  What we do know is a lot of grief was caused for what I would argue was no apparent long-term reason.