One of the more surprising facts that emerged from a Sept. 17 virtual seminar co-hosted by LDI and the Tradeoffs podcast is that, despite how often the topic is discussed and debated in government and regulatory circles, no one actually knows the total amount of money being lost to fraud in Medicaid.
Titled “Decoding the Moment: States Weigh in on Medicaid Fraud,” the University of Pennsylvania event featured Medicaid executives from New York, Nebraska, and Massachusetts; Penn Medicaid researcher and LDI Senior Fellow Paula Chatterjee, MD, MPH; and Dan Gorenstein, Founding Executive Director of Tradeoffs, who served as moderator.
The Medicaid officials were Amir Bassiri, MSW, Medical Director of the New York State Department of Health; Drew Gonshorowski, MS, Former Medical Director of the Division…
MANAGEMENT & CULTURE (THE “TONE AT THE TOP”)
Fraud thrives in “sloppy” environments where leadership ignores the rules.
- The Fraud Triangle: For fraud to occur, three elements must be present: Pressure (the need for money), Rationalization (thinking “I deserve this”), and Opportunity (weak controls). You can only control the Opportunity.
- Whistleblower Hotline: Provide an anonymous way for staff to report “odd behavior.” Most internal frauds are caught via tips, not audits.
- Background Checks: Conduct credit and criminal record checks for all employees in financial or data-sensitive roles.
- Annual Ethics Training: Make sure every staff member knows that the company has a Zero Tolerance policy toward “borrowing” from petty cash or fudging overtime.