Iowa Medicaid fraud task force recommends growing prosecution unit to 24 positions

DES MOINES, Iowa (Gray Media Iowa State Capitol Bureau) — Iowa’s Medicaid Fraud Elimination Task Force released its final recommendations, saying the state needs to expand the team that prosecutes fraud.

The task force is asking Gov. Kim Reynolds to approve 15 more members for the current nine-person Medicaid Fraud Control Unit.

Unit expansion

“Iowa has a strong False Claims Act, but not civil fraud attorneys to use it,” said Eric Wessan, solicitor general. “So the committee recommends a civil fraud component in the attorney general’s office and growing the medicaid fraud control unit to 24 positions with civil and criminal prosecutors and investigators, auditors, and analysts.”

The unit is a separate state-funded team of attorneys and investigators that already handles health care fraud cases. It is one of the smallest units in the country with nine members and is funded less than other states.

The recommendations say the unit already brings more criminal cases per employee than any unit in the country, but it has nine people overseeing an $8.7 billion program. The task force recommends growing it to 24 with dedicated prosecutors, investigators, data analysts and a nurse investigator. Investigators would get full law-enforcement authority, and the unit’s attorneys could prosecute fraud in federal court alongside U.S. attorneys.

The task force also recommends creating a fraud unit to monitor insurance provider data and payments.

Former unit leader questions timeline

Kevin Techau, a former attorney who previously led the unit, said the unit could have been helped already without the formation of the task force.

“Why did it take so long? Those answers were always there, those techniques, those resources, were always there and they stiff armed them and didn’t do their job,” Techau said. “And people have suffered and people have died because of that.”

Other recommendations

The task force recommends a Medicaid Fraud War Room based on the federal Centers for Medicare & Medicaid Services (CMS) model. When there is a credible allegation of fraud, Iowa could suspend payments to the provider within 24 hours while investigators build the case. The state would refer the provider for a nationwide ban from federal health programs within five business days.

Iowa Medicaid would also check enrollment against federal death records and screen high-risk claims before they are paid.

The task force also recommends:

• Making Medicaid fraud a felony on the same level as insurance fraud, with a higher penalty for thefts over $10,000.
• Putting repayment to Medicaid first in line when courts order restitution.
• Giving investigators authority to investigate confidentially.
• Enacting new state anti-kickback and civil penalties to stop schemes that fall under federal thresholds.

Provider verification and reporting

Iowa Medicaid would revalidate high-risk providers and deactivate providers who are not serving patients. It would use secret shoppers and data checks to confirm that providers listed in managed care networks are real and available. It would also modernize network standards last updated in 2016.

The recommendations say managed care companies made 21 fraud referrals last year. Under the recommendations, they would present their anti-fraud work in public.

The recommendations say fraud concentrates in high-risk services such as in-home care. The task force recommends using data to target reviews where risk is highest and strengthening electronic visit verification, which confirms that a caregiver showed up before the visit is paid for.

The state would also explain what Medicaid fraud is and how to report it, coordinate messaging across state agencies, promote IowaFraudFighters.gov and release a plain-language video on spotting and reporting fraud.

Cost and funding

The task force says growing the unit to 24 would cost the state about $550,000 more a year.

The federal government pays 75% of the fraud unit’s costs, according to the recommendations, so every state dollar brings in three federal dollars. Nationally, fraud units return $4.64 for every dollar spent.

Recovered money would continue to go back to Medicaid. New fraud-fighting technology would be tracked against what it recovers, with no new fund or added bureaucracy, according to the recommendations.

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Isabella Warren covers state government and politics for Gray Media-owned stations in Iowa. Email her at isabella.warren@kcrg.com; and follow her on Facebook at Isabella Warren TV on X/Twitter@isabellaw_gray, and on Instagram@IsabellaWarrenTV.