Data aids Medicaid detectives

They still employ old-fashioned methods straight out of detective novels — from chasing down leads from tipsters to hanging out with local police to wearing out shoe leather to root out crime.

But increasingly the sleuths rely on something else to spot fishy-sounding Medicaid claims among the hundreds of thousands made annually to the state: Computer data analysis.

These cases often uncover unscrupulous medical providers who develop schemes such as overbilling to defraud the state Medicaid program, which is jointly funded by the state and federal governments to provide health insurance coverage to the needy.

Some charge for services that were never performed.

Attorney General Thurbert Baker’s office helps in the investigations and prosecutions. Recovering that money — $26 million in fiscal year 2009 — is welcome, Baker told The Atlanta Journal-Constitution, especially this year as the state faces a $608 million Medicaid funding gap.

Computer analysis often works hand-in-hand with old-fashioned investigative work. One Medicaid fraud case against two men started with a traffic stop by the Twiggs County Sheriff’s Department. That’s when officers found labels for filled prescriptions in the car.

Over time, using techniques that included computer data analysis of these prescriptions, investigators discovered that Varian Scott of Miami and his cousin, Hezron Collie of Atlanta, were buying blank doctors’ prescription pads from a source at Emory University’s Winship Cancer Institute and other doctors’ offices in Atlanta and in Florida.

The two then forged prescriptions for cancer and HIV medications and resold the expensive drugs on the so-called “gray market” in Florida, according to a press release by the U.S. Justice Department.

All told, they bilked $1.1 million from state Medicaid.

Scott was sentenced in December to 12 years in federal prison. Collie, who cooperated with investigators, received a sentence of 18 months. They were ordered to jointly pay about $1.2 million to the Georgia Medicaid program.