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>> Good afternoon everyone.
Again, my name is Jacqueline Franklin and I could sum this up real quick and say all
that you've heard today don't-- if you do it correctly I won't end up at your door.
I've been dealing with Medicaid like I said,
for about twenty one years even though I don't look it but I love my job.
I love also being here in a place to where we come to where you fellowship and learn about how
to do it correctly and you have a chance to ask questions and inquire
about the right way to do something.
I think education is the best tool and I thank you for including and inviting my office
to participate, because we do work jointly with HHS, FBI in prosecuting cases
of only Medicaid here in the district, although it might reach into Virginia or Maryland.
But what we do, do is we don't go after people just to be going after them meaning
as Nick says somebody has referred it in, somebody from the Single State Agency has looked
at the data and determined that a flag went up.
Somebody's call because they read an ELB an explanation of benefits that says
"I didn't get this service on this date or I did get the service but the one
that was billed is not the one I received."
Or we have a hotline in which let me say that outside
on the table you will find some brochures that include our hotline number
but our referrals come in so many different ways that there is no telling it might even be staff
in the office that calls and says, "This is what's going on".
And it's not every time that you get a call that something is fraudulently wrong
or criminally wrong, it could be innocent.
And that's where it's like you have all these tools in front of you
to help you educate yourself on how to do things correctly.
And one of the things is that I've taken since I've been here listening this morning is
that everything is right there in front of you.
If you are the person signing up to provide the service with the District
of Columbia's Medicaid Program look at it like it's your responsibility
to make sure your house is in order.
Your staff needs to be educated, if you're going to be billing for certain codes
and procedures you ought to know which codes and procedures you can bill for.
However, I've heard about the self-disclosure, it occurs I'm sure.
But I just hadn't seen it yet.
[Laughter] I'm sure it happens.
And-- I'm sure it does because you have all these branches here so some people have seen it,
I'm just saying I have not because by the time I show up it's not a mistake, it's not an error.
When I see repeated claim forms that show the same thing over, over and over and over
and over I don't consider that an error.
Maybe you were misinformed.
But it's your responsibility as the provider.
It's your duty to make sure that everything that you're submitting
for reimbursement was submitted correctly, it's as they said, by the panel.
Claims are always good at face value.
It's easy to get a good claim through the system.
It's when you go back and you do the audit and you go back and you do the checks
and you go back and you look at those records that don't add up is as--
I forget the doctor's name who said,
"When document into your files make sure you document correctly
because if its not written it did not happen."
You verbally telling me oh yeah I did that that won't pan out because you're supposed to be able
to defend everything you've done and I would also like to include the part
about the repercussions as a provider.
Anytime, I don't care if it's a doctor, DME, whatever your specialty is,
anytime you do something-- and I'm speaking just for Medicaid,
but anytime you do something regarding a recipient you're creating a history
for that person.
So therefore if you're doing something to save or an example,
a doctor who says he's treating someone for mental illness and they came
and they did an hour's worth of a visit.
But now you've created a history diagnosis for this person
and if you're only doing it fabricate the claim
and get more dollars you now affected this person's history.
I don't think it's fair that in good faith somebody is coming to you
and then you're doing something to benefit yourself.
I'm not saying that's what's happening but that's how a claim can go through, be processed,
it'd be good, but the ramifications go further
than you just submitting a claim and getting reimbursed.
My office is located here in the district and we're about twenty one staffed up
and I think we have like two more coming aboard, another investigator.
And what we do is prosecute health care fraud criminally.
We also-- if we can't get through criminally we do look at civil and we do do the CMPs.
But we also, as I'm here today, educate.
I think that's the one thing that helps everyone 'cause everybody is
about being proactive and to educate is about that.
I like the idea that we all go out and we entertain and intermingle
and health care fraud does cease, I'm a more task force than you can imagine,
because new things always come about.
People are thinking of ways to get over that you wouldn't imagine.
And I don't know, maybe you're aware about, let's say I'm gonna call them medical gains
where groups come in they bill, bill, bill, bill then they get out.
They might ship the money to some other country, some other place but they find a way
to get the money then they run, but then here we come.
We're after the fact.
But as Dr. [inaudible]-- I'm sorry he stated there are so many things now we're going
to be proactive to prevent things happening before they can begin and I think in my journey
as an investigator and being part of a Medicaid, I've saw--
I've seen things where now we're at the point of where it's like we're finally getting a grasp
on it but we're always a step behind, but there's tools and there's seminars
and there's education and I welcome the fact there's so many people who want
to be providers, and we're talking about trends.
DMEs are one of the trends we see now because you have providers,
for an example, I have a case I'm looking at.
The provider has a DME number to do durable medical equipment
but they also have a pharmacy number to provide them prescriptions.
Why would a prescription ever be filed under a DME number?
But it's so simple to get through.
So therefore, that's something that will come to my door.
There's something when I show up at that pharmacist,
they're gonna have to explain why that did occur.
Other trends could be home health aids, there's a disconnect between showing up and working
for eight hours, signing a piece of paper saying you worked for eight hours
and actually working eight hours.
Because we found that some people, like you say, they have that dual thing going,
I work over here and I also work over here.
How you do that I do not know but somebody else does back.
And when it comes to validating your employees, your staffing,
making sure they don't have a criminal history, making sure their licenses are valid and current
and I'm in agreement that when you first hire somebody most
of the time that's what happens, you check it.
And you say okay he's clean.
They have no record.
But you might want to follow that up.
It would be good of you to keep abreast of what's going on, what your employees are doing
because again, it comes back, it's your responsibility.
It's your job to make sure your facilitating the best office you have
or doing the best service that you can.
But then you have all these tools that are available to you.
I love the fact that even though I do fraud which is my baby, I love my job.
I love chasing paper because I don't have to talk to anybody.
By the time I come to you I'd already got it laid out.
I've already did my due diligence by saying looking at the data, looking at your claims.
I probably sat outside your door and you didn't know it.
But I've done my due diligence.
I've done my home work.
By the time I show up, I know you're scheme.
I just want to hear what you're gonna tell me.
And it's as you said, you might get some untruths, you might get some I didn't know
or I've had cases which this lady, she-- it was a DME.
And what was happening was we had 7-19s that-- wow, this was back in 2002 I believe.
We had 7-19s which were pre-authorizations and the nursing home would say I need diapers,
wipes and chucks for-- that's all they were put on there.
But this little old lady on oxygen felt the need
to be the excellent billing expert she would add expensive items
that would make a 300-dollar claim go to a thousand.
So over time imagine how much money she made for this company?
Although we couldn't prosecute them criminally for what they did because it's a rogue employee,
but again it goes back it's your responsibility, it's your company.
So therefore, I don't know how this company didn't know they went X amount
of dollars to triple X amount of dollars.
I don't know how they didn't know that.
But the thing is the responsibility is one the person who agreed
to provide these services through Medicaid.
Another-- she spoke about record retention, make sure you're documenting,
make sure you're stressing that whoever is doing your records you do them in a timely manner.
You don't wait five days later.
When I show up you have that doctor [inaudible], 'cause I had a case where that occurred.
And it was through ink analysis that it was determined
that he didn't do the records when he said he did the records.
>> Or we have the case where the doctor saw patients twenty-four hours a day.
Another thing about our office, we're half care oversight, that means I can show up at any time
and ask you to provide me with access to records.
I am HIPAA compliant, that means I could see any Medicaid patient's records, I could look,
I can view, I can ask for a copy but then understand my role.
I'm the Medicaid Fraud Control Unit.
If you're a Medicaid provider then you understand why I'm here.
I'm here to do my job just as you're there to do your job.
But one of the things we do, like I say, I believe in education.
I went to inspect the General's office, we'd go out and we do do trainings.
We do help facilitate educating people about how to it the best way, the right way,
but that's what we've doing all morning when we're educating the community.
If you want to be a provider I mean I welcome it, I think it's admirable.
But you got time, okay, my time is up.
[Laughter] I did, I left some brochures and everything and cards out on the table.
Please feel free to contact me at any time, thank you.
[ Applause ]