For AMG-SIU, I’m happy to say, it’s been an up year. We’ve taken on several new clients, worked on fun special projects, and have grown our wonderful staff to a diverse group of intelligent and dedicated workers.

We’ve been very fortunate in the people we have working for us, they’re all very special and not only are they gifted at what they do but they want to be here. We try to make it special with the monthly birthday celebrations, holiday parties and occasional dinner cruise, but it’s truly our employees that make us special.

Thank you to all our employees for everything that you do, we really appreciate your hard work and dedication. It does not go unnoticed!

It was hard to believe.

Anyone who constantly monitors the Medical Fraud, Waste and Abuse business probably saw the news today, New York recovered more than $551 million in Medicaid fraud this year alone, more than double what officials had estimated. The shocking part of this news, was the press release that followed it. The New York State Comptroller, Thomas DiNapoli came out with a statement that the system New York has been using - isn’t working. The Comptroller’s office had recently overseen an audit of the system and turned up $1.8 billion in overpayments.

We come across fraud, waste and abuse daily - but we don’t normally come across a figure as large as $1.8 billion. After reading through all the issues we found that many of the problems facing New York were the same issues that our potential clients face, but without the $1.8 billion pricetag.

The Comptroller identified a few cases of fraud that had gone undetected by the system and most likely - would go undetected in most systems available today (except our own). Why is that? Most systems create edits based on federal guidelines and codes and leave it at that. We know better than that. Because we’ve been in this business for more than 35 years, we know that the rules do not include common sense rules. Long ago when edits were done manually, that was understandable but now you have to include these rules in your editing software. We have common sense edits in our system that would notice that it’s illogical to give one patient 35 fillings in one day.

Let’s hope that the next iteration of New York’s system will include logic as well as the required guidelines, and that they’ll be able to figure out when guidelines and rules are in conflict with another and how to rank them so that the edits follow all guidelines!

That took us several years to do on our own, but it’s been worth it. The last time one of our clients was audited, nothing came up. Zero! Nada! The auditors weren’t able to come up with anything wrong with their system.

It’s always nice when you find out all your hard work was worth it.

What did we find interesting? The focus on politics. The conference broke down both McCain and Obama’s different politics on healthcare and how it will effect our industry. Both of the candidate’s recognize the need for healthcare reform and that’s a great beginning.

One thing we hope that both candidates will employ in healthcare reform is education. We find that of the claims that come back as possible, fraud, waste, abuse or error - many of them are because the doctor, hospital, etc. didn’t have the background education on how to submit that claim properly. Education is a powerful tool, and hopefully it’s one that both candidates will wield.  

The conference was educational, with several sessions dedicated to the growing pains California is experiencing within the health care industry and how to make healthcare affordable to more Californians. 

With our background, we of course think that one of the first steps health plans should make is to ensure that they’re doing everything possible to reduce fraud, waste and abuse within their companies through a claims editing system and education. On average, we find that approximately 10 percent of health plans’ claims dollars are spent unnecessarily on claims that are fraudulent, wasteful or made in error. 

By working with us, one of our clients has significantly reduced the amount of fraud, waste and abuse to 1-2 percent of their claims dollars- and that number will go down even further as they continue their education efforts.      

More than 15 employees gave up their Sunday morning and arrived at Disneyland’s gates sporting their TEAM SIU t-shirts at 6:30 to walk around Disneyland and Disney’s California Adventure. The streets of Disneyland were more crowded than on a summer afternoon, and everyone was in a festive mood - with Minnie and Mickey waving and balloons filling the sky.

Today it was reported that a man committed identity theft from a Medicaid patient to receive heart bypass surgery. Typically when you see someone steal an identity for medical benefits – it’s a one-time event: not for John Parsons. Parsons repeatedly committed fraud to secure a heart bypass surgery.

I’m probably wondering the same thing you are – how did he do this?

According to initial reports, it was not the internal or external vendors who caught the fraud: it was the caregiver of the man whose identity was stolen, Philip Johnson. Our own solution reports when any permanent characteristic is inconsistent with what we have on file such as birth date, sex, height and so forth – so we’ll be watching this story closely to make sure our own solution is capable of finding this type of fraud.

For those of you who are unfamiliar, the National Association of Medicaid Program Integrity (NAMPI) conference provides states with a venue to share information about their Medicaid programs and help each other prevent fraud, waste and abuse.  

If you’re attending and see Lori or Barbara around the conference, please stop and say hi!