Georgia Department of Audits & Accounts

Michael Johnson, CPA & Seth Grad, CPA

Auditing Medicaid Systems

Medicaid In Georgia

• Administered by the Department of Community Health;

• ACS is the fiscal agent for claims payment;

• ESI processes pharmacy claims;

• Starting HMO’s for certain clients based on Eligibility—currently 2 regions started.

• SAS 70 required annually for above

What do we do?• Healthcare audit Division

Cost report type audits mostly nursing homes Audits are selected via electronic analysis

Claim Type Audits Fee for Service claims requires medical knowledge Audits are selected via electronic analysis

Program Audits Data Mining and Analysis

Work starts with warehouse with 7 years data

Cost Report Audits

• Providers submit their cost report information electronically via an Excel document prepared by DOAA

• Providers cost report information is uploaded into a rate calculation program and providers are selected for audit

Cost Report Audits (cont.)

• Once selected for an on-site audit, the provider submits financial information electronically

• Information is analyzed and risk assessed using ACL

• Audit is conducted using ACL and AS2

Claims Audits

• Most audits to date have been physicians

• Audits are selected based on reports produced by Claims Analyst

• Audit teams consist of RN and financial auditor

• ACL and AS2 are used to conduct the audit once the provider is selected

Claims Audits (cont.)

• Most audits have included a recommendation for recovery of funds

• Currently 16 million +

• Some audits may include prosecution for fraud

Program Audits• Reviews portions of the Medicaid program

for effectiveness

• Uses data from Medicaid warehouse to draw/support conclusions

• May address problems/shortcomings related to a particular program

Claims Analysis• Built a data warehouse containing 7 years of

Medicaid data;

• Data comes weekly from multiple sources via tape, CD, or the internet;

• Data is loaded and reconciled to financial records at DCH.

• Additional supporting tables are updated on weekly, monthly, or quarterly schedules

Claims Analysis (cont.)

About Our Data• Data is 27,000 bytes wide for each claim and

is variable length

• Multiple lines of detail exist for each claim

• Claims data arrives on 3490 tape

• Is mostly EBCDIC and packed decimal

• Has 4 different layouts based on Claim type

Claims Analysis (cont.)

• Data is read using base SAS

• Data is separated into 4 main tables based on claim type

• Data is stored by fiscal year based on payment date

• Data is set to read only for staff

Claims Analysis (cont.)

• Claims Analysis staff responsible for producing reports;

• Information may be based on known fraud schemes;

• Also let the data tell us who the outliers are for particular areas

• All claims analysis staff learned how to program in SAS;

Claims Analysis (cont.)

• Started with “low hanging fruit”;Used RBRVS to determine who was “working

more than possible” based on Medicaid only population

Found several providers who were openly committing fraud and abuse and admitted as much when asked

Years later, still find many “low hanging fruit” based on different queries

Claims Analysis (cont.)

• Using SAS AF, gave audit staff easy access to the data to query provider specific information;

• Once downloaded from the warehouse, auditors access the data via ACL;

• Claims Analysis staff has written many standard query’s in ACL to automate the staff’s standard reports on a provider;

Claims Analysis (cont.)

Warehouse is also used as a tool during the Audit of Medicaid

• Conduct reviews on all claims to look for duplicates, overpayments, etc.

• Pull some samples for more detailed eligibility review;

• Perform other detailed analysis as requested

Claims Analysis (cont.)

Warehouse provides information for Program Audits

• Data is queried to provide program information that is not readily available;

• Are able to provide any historical information based on multiple conditions

Using ACL

ACL• ACL is an integral part of our audits.

– All employees are required to understand and utilize ACL.

• Training is provided in-house by our IT staff.

– Auditors work with our IT staff in the procurement, definition and validation of auditee data.

– Our IT staff creates “Standard Applications” to simplify common ACL procedures.

ACLP

rocu

rem

ent • With ACL, we have flexibility when

dealing with both media and file format.

• Acceptable Media Formats:– FTP, CD-R, floppy, Zip disks, 6250 BPI tape,

3480 or 3490 cartridge tape, 4MM tape.

• Acceptable File Formats:– ACL accepts just about any format.

• ASCII, EBCDIC, PACKED, BINARY, PCASCII, DBASE, EXCEL, etc….

ACLS

tand

ard

App

lica

tion

s • Our IT staff uses ACL to create Standard Applications (SA’s).

• SA’s like this provide an intuitive GUI that is beneficial to both novice and experienced ACL users.

ACLS

tand

ard

App

lica

tion

s • Some common audit procedures for which we’ve written SA’s:– sampling– search for large, even dollar amounts– search for duplicate transactions– querying data sets using selected criteria

Integration• The ACL SA’s are designed to work in

conjunction with our AS/2 templates and audit programs.

ACL AS/2

Integration• Here, we see an SA which pulls a sample

for vouching, followed by an SA which combines and exports several samples in Excel format, for use in an AS/2 workpaper.

Integration• On the AS/2 side, we can use a Visual Basic

macro to import the sample onto our workpaper.

The Future• Obtaining other healthcare related data owned

by the state that is “non-medicaid” to have a greater picture of a provider’s practice

• As GA goes to more HMO claims, the focus of our analysis and query types change

• Using additional SAS tools (neural nets, artificial int.) to stay ahead.

• Looking into changing our electronic workpaper program (AS2).

QuestionsMichael Johnson

404-463-2663

johnsonm@audits.ga.gov

Seth Grad

404-463-2667

gradsa@audits.ga.gov