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, policy and/or system edits may be modified, and administering the provisions of the False Claims Act.
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 actions.
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, 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.