Alliance Compliance Team Stands Strong against Fraud, Waste and Abuse

Alliance Health’s commitment to delivering high-quality services at a sustainable cost to the people we serve includes robust, proactive efforts to promote compliance and ethics among Alliance staff, providers and members.

“Compliance and ethics lay the groundwork for what we can and should do, how we should behave, and how we should interact with each other, the members we serve, and our providers,” said Matt Ruppel, Senior Director of Program Integrity.

Ruppel said one way to understand these concepts is that compliance will tell you what you can do, per laws and regulations, and ethics are what you should do. “One isn’t any more important than the other, they both hold the same value as far as I’m concerned,” he said.

A large part of our effort is a serious and proactive commitment to minimize the impact of fraud and abuse in the Medicaid system. “Every dime, every penny we lose to fraud, waste, and abuse is that much less money that is available to help our members get legitimate services,” Ruppel said.

In healthcare, fraud is when someone intentionally lies to an insurance company, Medicaid or Medicare to get money, waste is when health services are carelessly overused, and abuse happens when best medical practices aren’t followed, leading to expenses and treatments that aren’t needed.

Ruppel said healthcare anti-fraud groups report that about 10 percent of all money spent on healthcare is fraudulent, which can amount to billions of dollars across all commercial health plans, Medicaid and Medicare. “So anything we can do to prevent it is the most important thing,” he said.

“We spend a lot of our time recovering money, and investigating things that seem like they went wrong,” Ruppel said. “And the best thing we can do is prevent it from going out in the first place. Because once you pay that money out, it’s hard to get it back.”

To uncover fraud, waste and abuse, Ruppel’s team uses claims audits and data analytics to help identify aberrant billing that could signal wrongdoing, carelessness or lapses in oversight. They also rely on tips or alerts from Alliance staff or others involved in member care.

“The more that our employees can be educated about it, the more they can recognize an issue and say something if they see something,” he said. “And we want people to say something even if they’re not sure if it’s fraud. If you think it’s not right, report it, we’ll investigate it and figure it out.”

Ruppel’s team, the Special Investigations Unit, follows up on tips and alerts with diligent detective work, poring over records, reviewing provider monitoring data and interviewing staff, members and providers. When they determine that fraud has likely occurred, they refer the case to the NC Medicaid Office of Compliance and Program Integrity. If that office decides it’s a credible case, they send it to the Medicaid investigations division for criminal and civil investigation.

In some cases the unit’s investigations reveal that suspected fraud is actually the result of carelessness or shoddy practices by provider staff. “We often see bad controls and providers with an employee or maybe several employees that are cutting corners,” Ruppel said. The compliance team works with those providers to help them understand why they need to develop better controls and educate their staff.

Ruppel said that individuals can do their part to prevent healthcare fraud by safeguarding their health identity and their member number. “The best advice I can give is to treat it like a credit card, don’t just give it out,” He said.

He also advised to not sign documentation that is not complete or that you do not understand, and to always date anything you sign. “We will find treatment plan and signature pages where the guardian has signed it but there’s no date. So then that becomes the template that the provider will use whenever they need a signature page updated,” he said.

Learn more about Medicaid fraud and abuse at AllianceHealthPlan.org.