Optum has begun reviewing Minnesota Medicaid claims as part of an enhanced prepayment audit, state officials said, as the state grapples with a widening fraud crisis in its public assistance programs.
On Jan. 5, Minnesota Gov. Tim Walz said he will not seek a third term, saying he needs to focus on fraud prevention efforts rather than a reelection campaign.
More than 80,000 claims have been sent to Optum in the first round of reviews, KSTP reported Dec. 29. The claims cover 14 Medicaid services the state designated as high-risk based on vulnerabilities, evidence of fraudulent activity and data analytics showing suspicious billing patterns.
“It does not necessarily mean that there is a problem with those claims or that there was something inherently concerning about them; we’re just doing prepayment review in this enhanced fashion,” John Connolly, deputy commissioner at the Minnesota Department of Human Services and state Medicaid director, told KSTP.
Another set of 80,000 claims will be reviewed every few weeks, according to the report. Optum’s analytics will identify irregularities such as missing documentation, unusually high billing patterns or inconsistencies suggesting a claim may not meet program requirements. Claims flagged during review will be sent to the state’s Office of Inspector General for investigation.
Gov. Walz announced the prepayment review program in October, pausing payments for the 14 high-risk services for up to 90 days while the third-party audit is conducted.
The affected programs include early intensive developmental and behavioral intervention for autism, integrated community supports, nonemergency medical transportation, peer recovery services, adult rehabilitative mental health services, adult day services, personal care assistance, community first services and supports, recuperative care, individualized home supports, adult companion services, night supervision, assertive community treatment, intensive residential treatment services and housing stabilization services.
The audit comes as federal prosecutors estimate losses could exceed $9 billion across multiple Medicaid programs in the state, though Gov. Walz has disputed that figure, according to CBS News. Federal investigators said their probe extends to more than a dozen social services programs, including nutrition, housing and behavioral health.
