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 provider fraud,
waste, abuse, and improper payments is known as the Surveillance and
Utilization Review (SUR) Unit. The SUR Unit identifies aberrant billing
practices, educates those who have improperly billed the Medicaid program,
recovers overpayments, recommends sanctions for those who abusively bill
Medicaid, and assists in criminal investigations when appropriate.
The SUR Unit performs a variety of other functions, such as detecting areas
where Medicaid regulations and/or policy may be modified, administers the
provisions of the Federal and Nevada False Claims Acts, conducts provider
training on fraud, waste, abuse, and improper payments, and prevents fraud and
abuse from occurring.
Types of Provider Fraud/Abuse
Provider fraud includes
intentionally billing for services not 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. Abusive billing may include billing for
excessive services, consistently billing for the most expensive services
possible, patient sharing, or rendering medically unnecessary services. These
are some of the types of abusive billing used to over-bill Medicaid. Program
losses can also result from inadvertent billing errors. The SUR Unit distinguishes
among the various kinds of losses and takes the appropriate administrative
Proving fraud is an
extensive process that requires expert investigation and analysis. The SUR Unit
of Nevada Medicaid is comprised of Administrative Staff, Analysts, a Registered
Nurse, and Certified Professional Coders. Upon determining there is a credible
allegation of fraud, the SUR Unit refers the matter 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 the SUR
Unit can be found by clicking on the MSM Chapter link under Regulatory.
Detecting Fraud and Abuse
The SUR Unit conducts
both random reviews and focused reviews. Providers may be 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 the SUR Unit 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,
waste, and abuse detection on a national level. Not all outliers are caused by
improper practices, but when these providers are identified, they may be
reviewed in greater detail to ensure that their billing is appropriate.
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 whether or not they received the services
billed to Medicaid on their behalf, and report any discrepancies. The SUR Unit
reviews reported discrepancies, and takes action as appropriate.
The SUR Unit also receives referrals from other governmental entities,
providers, provider employees, recipients, and other members of the public.