As Medicaid costs grow, Delaware lawmakers propose crackdown on fraud and waste

The Delaware Department of Health and Social Services presented the Division of Medicaid and Medical Assistance budget request in Dover where they asked for an additional $25.6 million to fund Medicaid.

The additional need for funds comes as the Federal government changes the way Medicaid costs are split.

Of the DHSS’s $1.1 billion budget, more than half is appropriated to the Medicaid and Medical Assistance Division.

Division Director Steven Groff said more than 200,000 Delawareans are enrolled in Medicaid and they’re expecting those numbers to grow as more people take advantage of the Affordable Care Act.

As Medicaid costs continue to rise, Delaware lawmakers want to see a more done to combat and recover funds that are mixed up in waste and fraud.

Sen. Karen Peterson (D-Stanton) said a recent national report she read showed a low average of seven percent of Medicaid cases are fraudulent or wasteful.

As an example, she said, “That would put our waste fraud and abuse in Delaware at $47 million.”

Medicaid fraud and abuse is a national problem with some states reporting that as many as 12-percent of all cases are fraudulent.

Peterson added that Delaware has a “pay and chase” approach, where it pays claims first and follows up on fraudulent or wasteful spending later.

Groff said they do not have exact data on exactly how many cases in Delaware are fraudulent.

“I would hope or like to think that there are some things about Delaware, that our rates would be a little bit lower,” said Groff. “Things we have, like the prescription drug monitoring program now and we have very aggressive benefit limits on our prescription drug program.”  

He said the state uses the Surveillance and Utilization Review Unit to look at claims data and target providers or individuals that could be abusing the system.

“When we find instances that have creditable activity, they’re referred to the attorney general’s office and the Medicaid control fraud unit,” he said.

Peterson noted that the AG’s office has recovered less than $2 million in Medicaid fraud cases.

She said she’d like to see more done “on the front end” rather than chasing down claims later on.

One suggestion is implementing Medicaid cards, which would feature a chip full of the patient’s medical data.

The card would keep track of tests and procedures that the patient has already had done to prevent duplication which can become costly.  

Groff said they’ve looked into that kind of solution however he said they have some concerns about patients carrying around that kind of information due to HIPAA and other laws.  

He said they’re also continuing to implement the statewide health information exchange.  

DHSS will continue their budget requests in Dover on Thursday.