Surveillance and Utilization Review Unit
Report Provider Fraud / Abuse
(775) 687-8405 (Northern or Southern Nevada)
Report Recipient Fraud / Abuse
Northern Nevada (775) 684-7200 or (775) 448-5298
Southern Nevada (702) 486-1646 or (702) 486-1875
It is imperative to have an effective way to protect the integrity of the Nevada Medicaid Program. Between 7 and 14 percent of all health-care expenditures are improperly made, according to government estimates.
The program that protects the integrity of Nevada Medicaid from fraud and abuse is known as the Surveillance and Utilization Review Section (SURS) Unit. The SURS program guards against fraud and abuse by providers. It identifies aberrant billing practices, sanctions those who have abused the Medicaid program, recovers overpayments, and assists in criminal investigations when appropriate.
SURS performs a variety of other functions, such as detecting areas where Medicaid regulations can be improved, finding contradictions in policy, administering the provisions of the Federal and Nevada False Claims Acts, conducting provider training on fraud and abuse, and preventing fraud and abuse from occurring.
Types of Provider Fraud/Abuse
Provider fraud is the criminal act of intentionally filing a false claim. Typically, the claim is for services that were not actually rendered. Abusive billing by providers that is not fraudulent is the most common cause of loss and accounts for the greatest financial loss to the Medicaid program. It may take the form of billing for excessive services, consistently billing for the most expensive services possible, patient sharing, or rendering medically unnecessary services. These are only a few of the many scams used to over-bill Medicaid. Proving fraud is an extensive process that requires expert investigation and analysis. The SURS Unit of Nevada Medicaid is comprised of Analysts, Registered Nurses, Certified Professional Coders and Auditors.
Program losses can also result from inadvertent billing errors. SURS distinguishes among the various kinds of losses and takes the appropriate administrative actions. When there is reliable evidence of fraud, the provider is referred to the State's Medicaid Fraud Control Unit of the Attorney General's Office for criminal investigation. Detailed information about the various administrative actions available to SURS can be found by clicking on the MSM Chapter link under Regulatory.
Detecting Fraud and Abuse
SURS conducts both random reviews and focused reviews. Providers are selected for review based on information that points to an irregularity in billing practices including data analysis, reports of improper billing received from various sources and known areas where providers have been found to improperly bill the Nevada Medicaid Program. A data mining program is used by SURS to identify outliers among various provider types including providers that bill high numbers of services, have high costs per patient, bill for seeing high numbers of patients per day and other algorithms that are used for fraud and abuse detection on a national level. When these providers are identified they are targeted for investigation.
Additionally, 500 verification of service letters are generated on a monthly basis to randomly selected recipients. These letters provide a summary of benefits paid by Nevada Medicaid on behalf of the recipient. The letter requests that the recipient review the summary and verify whether or not they received the services billed to Medicaid on their behalf. SURS reviews recipient responses to these monthly mailings and takes appropriate action if the services were not received by the recipient.
SURS also receives referrals from other governmental entities, providers, provider employees and from the public.