When it comes to Medicaid fraud enforcement, efficiency reigns supreme

If you're like me, the beginning of March signifies the start of one important pastime: Baseball spring training is in full swing, which means Opening Day is just a few short weeks away.

Maybe that's why baseball was the first thing that came to mind when I saw the recent state-by-state Medicaid Fraud Control Unit (MFCU) data from 2014, released last week by the Office of Inspector General (OIG).

It's a sport in which, traditionally, the biggest hitters draw the most attention. Everyone, regardless of his or her affinity for baseball, knows the name Babe Ruth because, until 1974, he hit more home runs than anyone else.

Similarly, when it comes to fraud recoveries, the biggest numbers draw the most attention. That monetary figure of annual fraud recoveries serves as a nice, simple way to gauge your state's productivity.

Take New York, for example, which fittingly might be considered the Babe Ruth among the state Medicaid fraud enforcement units. Last year, New York brought home more than more than $378 million, outpacing the rest of the field by well over $100 million. The state also gets paid like an All-Star. In 2014 it received $45.8 million in MCFU grant money for a staff size of 294. The next highest was California with $26.1 million for 193 staffers.

But baseball fans know that the flashiest numbers don't always paint the most detailed picture. As such, a subculture of baseball fans devoted to sabermetrics--which offers exhaustive empirical analysis of almost every aspect of the game--has emerged in full force. Now, instead of gravitating toward a player who hits the most home runs, a team might find more productivity and value in a player who gets on base a lot. Suddenly, on-base percentage has become a more treasured statistic than home runs or RBIs.

Which brings us to Louisiana, a state that recovered more than half the amount of New York, but with a fraction of the budget and staff. All told, Louisiana recovered $245.3 million in 2014--including $118.8 million in criminal recoveries, which ranked first among all other states--but received just $5.1 million in MFCU grant, with a staff of 52.

To break that down further, Louisiana recovered $48 dollars for every dollar spent on Medicaid fraud enforcement. By the same measure, New York was six times less productive, recovering $8 for every dollar spent.  

Furthermore, Louisiana has demonstrated consistency. In 2012, the state recovered $124 million with $4.6 million in grant money, and in 2013, it Medicaid fraud units brought in $187.6 million on a $4.8 million budget. Those numbers put Louisiana among the top five states in recoveries each year. Meanwhile, the state usually ranks below the top 10 in terms of grant money.

Why or how Louisiana remains consistently efficient is an elusive answer. In a statement, Louisiana State Attorney General James "Buddy" Caldwell chalked it up to "well-trained, experienced and aggressive staff members," and the state's collaboration with "experienced, complex litigation lawyers" as well as law enforcement agencies and prosecutors that work in Medicaid fraud.  

That sounds nice, but it doesn't offer much in the way of specifics. A look back at Louisiana's enforcement trajectory offers a few hints. A Law 360 article published last January pointed to Caldwell's aggressive approach to pharmaceutical fraud, and a 2009 initiative honed in on home health fraud within the state.

It also seems the state has a close working relationship with the Department of Health and Hospitals (DHH) Medicaid Program Integrity division. A 2010/2011 Louisiana Medicaid report (.pdf) indicated that prepayment review processes, including "claim edits, ClaimCheck, InterQual, Radiology Utilization Management, pre-certification and prior authorization" have allowed for a close working relationship with the state's MFCU. In 2012, for example, DHH made 186 referrals to the Attorney General's office.

Whatever Louisiana is doing, it seems to be working, and some states could probably use their advice. Larger states like Texas ($6.4 recovered per dollar spent), California ($3 per dollar) and Florida ($5.9 per dollar) are reasonably efficient. Meanwhile, states like Pennsylvania ($1 recovered for every dollar spent), Montana ($0.60 for every dollar) and Arizona (a paltry $0.23 for every dollar) could desperately use some lessons on efficacy.

That, it seems, is the more telling statistic. The eye-popping recovery numbers are fun to compare in their own right, but in a time when budgets and resources are shrinking, and fraud is growing, doing more with less is a true measure of success. - Evan (@HealthPayer)

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