By NICOLE CARTRETTE

Several county officials have their eyes on computer software designed to detect Medicaid fraud.

Last week, representatives from the Salient Performance Management Solutions, a New York firm, gave a presentation on their product, which rapidly compiles data and is being used in several New York counties to combat Medicaid abuse. The gathering was a joint meeting between the Columbus County commissioners and the newly formed Medicaid Advisory committee.

“It’s the fastest computation engine on the planet,” Mike Boyle, a Salient representative, said as he showed how the product can be used to monitor both Medicaid recipients and providers. The data can be sorted instantaneously to indicate how many prescriptions a physician is giving and individual recipients are receiving. The service gives accountability of where money is going and can be used to possibly identify recipients who are abusing prescriptions by analyzing abnormal patterns. Physicians who are prescribing name brand drugs rather than generics can be identified too, he said.

“My staff are not physicians,” Marva Scott, director of Columbus County Department of Social Services, said. “How can I tell a physician to give a generic prescription?” she asked, adding that the state already provided the department with the information.

Boyle emphasized that it was the company’s ability to pull data from a number of sources, at state and local levels, and put it into an easy-to-use format that set the service apart. “In New York, counties didn’t have the ability to drill into the data,” Boyle said. “The idea is to analyze data quickly and rapidly.”

Representatives showed how information such as managed care services, could be grouped and graphed in seconds, along with analyzing weather conditions and the impact on services sought.

“That’s just a small portion of what we are capable of doing,” Boyle said, adding that it is up to the county leadership to determine how the information will be used. “One county may look at providers while another just looks the recipient end. It depends on the need of the county.”

Some questioned what it would cost in manpower to facilitate the system and investigate the patterns used to zero in on potential fraud, while others questioned the compatibility of the software with other programs and software in place.

Boyle explained that updating could be scheduled anytime and on a schedule that is compatible with the department’s operations.

Each county DSS in North Carolina has the central role in determining Medicaid eligibility for residents based on federal and state policies. There is at least one fraud investigator on staff per county, according to the N.C. Division of Medical Assistance (DMA).

According to the DMA, Program Integrity staff use “sophisticated computer software in a unique fraud and abuse detection system.” In addition, certain prescriptions, such as OxyContin, require prior approval, as do nursing facilities, behavioral health, certain specialized therapies and managed care.

In 2004, North Carolina awarded a multi-million dollar contract to Affiliated Computer Services (ACS) to install and support the N.C. Medicaid Fraud and Abuse Detection System (NCFADS). In July of this year, the state terminated the contract, citing allegations that the company failed to meet staffing levels and did not complete terms of the agreement.

In a letter addressed to county directors of social services in May of this year, Assistant Secretary Dr. L. Allen Dobson brought attention to 2005 county audit findings. He cited lack of proper documentation in case records, case files containing incomplete budget information, cases in which individuals had received Medicaid transportation assistance even though eligibility for Medicaid was terminated and the inability on the part of agencies to locate a file for audit as deficiencies. However, in 2004, the division reported that the state has never been penalized for exceeding the 3-percent federal tolerance level for payment error rates.

Medicaid was formed by the federal government in 1965 to assist states in providing medical services to the poor. North Carolina gained federal approval of its program in 1969.