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Barbara Skoglund's avatar

My state's circa 1990 Medicaid claims payment system doesn't even have the capacity to talk to other agency systems, let alone other state systems or federal systems. The public sector technology infrastructure is beyond outdated! There can be no data analytics, AI, without modern tech systems and data sharing.

There are a few additional key fraud fighting measures that are being overlooked. The high risk fraud categories for both Medicare and Medicaid are unlicensed services. The legal and financial investment required to become an unlicensed provider is obscenely low. Literally "anyone" can provide autism services, home care, durable medical, medical transportation, respite care, adult and child day care, and so on. We need to professionalize these services, require licensure for both direct service providers and provider agencies. The criteria to become a provider in the first place needs to be strengthened. Provider enrollment fees must be increased to support the cost of annual recertification visits and other program integrity measures.

We need to make it impossible for repeat fraudsters to become providers ever again. Penalties are LOW and we do not issue lifetime bans. Just as convicted child sex predators aren't allowed to become teachers when they get out of jail, convicted health care fraudsters should not be allowed to start a new agency once they have done their time. AND the business partners and family members should not be allowed to start new companies. AND they need to be banned from any kind of public service provider.

Sadly agency, state and federal leadership do not use the insights of frontline state employees, direct care providers and other grunts to fix problems. Instead whistleblowers are punished, not listened to. TRUE LEADERSHIP means listening to the people who actually know what's what. I've never seen a task force that ever included frontline staff let alone consulted with them.

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