ACS’ Fraud, Abuse Detection System Helps in Recovering $1.1M in Misspent Medicaid Dollars in Mont.

ACS, a provider of business process and information technology outsourcing solutions, announced that its Fraud and Abuse Detection System, which has been operational in the Montana Medicaid program as part of ACS’ comprehensive fiscal agent (FA) solution, has helped the State identify and recover $1,175,351 in provider billing errors and overpayments.

About one quarter of the recovery was State money and the remainder was federal dollars. The recoveries occurred during the State’s 2002 fiscal year (FY), which ended June 30, 2002. Recoveries were almost double those of FY 2001 and almost triple those of FY 2000.

The State of Montana credited the growth to four technological advances that ACS developed in partnership with the Medicaid program. These advances are:

*Creation of a computerized “claims warehouse” allowing easy access to 18 years of paid claims data;
*Implementation of OmniAlert, an ACS fraud and abuse detection software product that uses sophisticated computer algorithms to help State investigators identify anomalous patterns in claims from health care providers;
*Implementation of QueryPath, an ACS software product that enables detailed analysis of claims data;
*Creation of a customized case-tracking database for the Montana Surveillance and Utilization Review Section (SURS).

The vast majority of recoveries are reportedly due to incorrect billing practices or failure to follow current regulations. ACS and Medicaid staff work with many providers to educate them about correct billing practices. About 3 percent of cases, however, are more complex and are referred to the Montana Department of Justice for further investigation.

Since 1984, ACS has served as Montana’s fiscal agent (FA) contractor. For Montana, ACS processes and adjudicates over 5.2 million claims annually, which represented $534 million in claims payments in FY 2002. ACS’ responsibilities include full FA operations and maintenance, modification, and enhancement of the Medicaid claims processing system.

ACS also provides a full range of third-party liability responsibilities including resource verification, carrier billing, and casualty claims reporting; pharmacy benefits management; and provider relations. ACS recently received a one-year contract extension through June 2005.