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Surveillance and Utilization Review
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It is important to have an effective program to protect the integrity of Medicaid. Between 7 and 14 percent of all healthcare expenditures are improperly made, according to government estimates.
The program that protects the integrity of Alaska Medicaid from fraud and abuse is known as SUR (Surveillance and Utilization Review). This program guards against fraud and abuse by providers and recipients. It identifies aberrant practices, sanctions those who have abused Medicaid, recovers overpayments and assists in criminal investigations where appropriate.
SUR performs a variety of other functions: such as detecting loopholes in the regulations, finding contradictions in policy, assuring equal access to quality healthcare for Medicaid recipients as well as preventing fraud and abuse from occurring.
Types of Provider Fraud/Abuse
Fraud is the criminal act of intentionally filing a false claim. Typically, the claim was for services that were not rendered.
Abusive billing by providers that is not fraudulent is the most common cause of loss and accounts for the greatest financial loss. It may take the form of providing 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 devices used to overbill Medicaid. Proving such charges as providing medically unnecessary services can be difficult and requires expert investigation and analysis.
In addition, program losses result from innocent errors or lack of understanding. SUR distinguishes among the various kinds of losses and applies the appropriate solution. For example, a provider who underbills and loses more money than he makes by overbilling needs education and SUR will require him to learn how to do it right. When there is reliable evidence of fraud, the provider is referred to the state's Attorney General for criminal investigation.
Recipients do not receive Medicaid payments, and so recipient abuse takes other forms. The most common recipient abuse involves physician or drug shopping. When this happens, the individual can be "locked in" to a single provider or be required to repay inappropriate Medicaid expenditures.
Detecting Fraud and Abuse
SUR never conducts random audits. Providers and recipients are selected for review based on creditable information that points to an irregularity. The heart of the detection process is a sophisticated computer program that screens all provider billing and recipient services to flag aberrant findings. Once identified, the provider or recipient is then reviewed. This exception profiling examines includes all providers and recipients.
There are various other means of identifying non-compliant providers and recipients. SUR gets referrals from other government entities and from the public. You can also get the form you can use to report suspected Medicaid fraud or abuse.
Fraud and Abuse Complaints
If you have any concerns regarding the Alaska Medicaid services rendered or received, please complete the Suspected Fraud and Abuse Complaint Form to the best of your ability. It will be acknowledged, investigated, and handled accordingly. These complaints are strictly confidential and if you provide your personal contact information, please be assured that it will be kept confidential.
When an analysis of a provider's records shows that program rules have been violated, a sanction can be applied. The provider is notified of the sanctions and given an opportunity to explain and/or rebut the findings. If desired, the provider may have a face to face meeting with the person who made the decision to sanction. If, after this meeting, the decision is still unfavorable then the provider may request a formal appeal. The formal appeal is conducted by a different entity than the one that imposed the sanction.
There are a variety of sanctions that can be imposed. The mildest is a warning letter that educates the provider. No sanction is imposed without concrete evidence of abuse.
What you can do
Reporting suspected Medicaid fraud or abuse has never been easier. You may use the Suspected Fraud and Abuse Complaint Form for online reporting or you may call our Fraud Hotline at (800) 256-0930. While we prefer to have a way to contact you in case we need more information; you may report anonymously if you wish. Besides helping to identify those who would abuse Medicaid, citizens act as a powerful deterrent to those who would exploit the Medicaid program.