AGENCY BUDGETS DIVIDED BY RECOVERIES = RECOVERY VALUES
In any endeavor effectiveness can only be based on business values. If a market is $1 million there
are 10 competitors and your business capturers $100,000, if your costs remain as they are, your
business should last, but probably will remain 10% of the market.
If more competitors enter your market yours must increase or prices and/or decrease your costs to
retain 10%. This all depends on targeting customers and most endeavors seek to capture the
customers that use the most, often having to reduce the price while providing equal or better
quality or service to retain or grow the business.
In the “business” of fraud recovery enforcement agencies are required to pursue the most numerous
cases provided by fraud capital HOT LINES which often or simply answering machines and frequently
messages are not returned. But there is only one major customer for Medicaid Fraud Control Units
which is the state Medicaid program itself. And in the average state there are many tens of
thousands of complaints made each year however records are not shared publicly because the public
would be extremely upset to know that in most cases their complaints received no attention at all.
When this happens and the taxpayer is very upset and often contact their local state senator or
delegates to act in their behalf. Normally politicians offices will call in the complainant will
receive a telephone call but usually no results.
Almost all Medicaid complaints are filed against providers many against physicians or physicians’
offices and most concern billings. So if you get mad at a physician or other provider if you and
your friends make enough complaints, chances are it will garner an investigation. To get
investigated a physician has no protection and the way most complaints are settled is Draconian.
The normal process is to audit the physician or provider for a period around the time the complaint
was filed. Any billing mistakes are then multiplied by many months the provider has been supplying
Medicaid, and Medicaid then demands that amount as a settlement.
This process is totally absurd because it is based on the process that the provider has made an
equal number of mistakes or false billings everyone of those months. The provider does have a
choice to make pay the amount specified or hire an attorney.
Providers do have a choice in accepting new Medicaid patients, but most can’t survive not accepting
any entitlement patients. With the shortage of physicians and nurses now in high demand. Increasing
numbers of Medicaid patients end up in their local hospitals emergency room for their health needs
– large and small.
The only other source of MFCU cases come from qui tam cases often much larger than all the HOT LINE
cases combined, and staff time and required personnel are not capable of handling complex and
complicated qui tam cases and depended on U.S. Attorneys Offices to do the Heavy lifting while they
will do nothing unless the Justice department allows them to. The recovery
amounts for all of them is less than a half of 1%!