North Carolina Gets New Tool to Fight Medicaid Fraud

Last year, the State of North Carolina spent approximately $10 billion paying Medicaid claims. A certain percentage of those claims were fraudulent, but identifying the false claims can be hard. The chances of catching Medicaid fraud has been substantially increased by the implementation of the new IBM fraud detection computer program. The program uses mathematical and statistical analysis to locate abnormalities in Medicaid billing. Experts predict that a new fraud detection computer program could save North Carolina as much as $200 million a year, according to WRAL.com.

North Carolina’s Medicaid program receives 88 million claims each year. The sheer volume of claims can make it very difficult for people to spot questionable billing patterns. But some incidences of fraud should be easy for a computer to detect. For example, last year the name of a single North Carolina therapist was linked to claims for 22,984 hours of therapy—despite the fact that a year only has 8,760 hours. According to the Medicaid claims filed in her name, she was somehow working an average of 60 hours each day.

The North Carolina Heath Department is investigating the suspicious billing connected with her name and submitted by more than one North Carolina clinic. The Department of Health has suspended Medicaid payments to one clinic pending further investigation because of credible allegations of Medicaid fraud.

So far, North Carolina is the only state using the IBM fraud detection computer program, but the program has already spotted approximately 200 providers that need further scrutiny. Perhaps more states will follow.

Waters & Kraus is a national firm with highly skilled lawyers practicing qui tam litigation in four offices, including Dallas, Los Angeles, San Francisco, and Baltimore. Our attorneys have decades of experience successfully representing whistleblowers in a variety of fraud cases. Contact us or call our attorneys at 800.226.9880 to learn more about our practice and how we can assist.

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