S2 E2: Protecting Iowa’s Most Vulnerable: Inside the Medicaid Fraud Control Unit

In this episode, DIAL Communications Director Stefanie Bond sits down with Bureau Chief Jeremy Ingrim of Iowa’s Medicaid Fraud Control Unit for a behind-the-scenes look at how MFCU protects vulnerable Iowans and safeguards taxpayer dollars. We break down unit investigations, working with Iowa HHS and DIAL’s health facilities staff, and how criminal cases get prosecuted. 

Find more information on our website about the types of fraud, abuse, and neglect that MFCU investigates.

Transcript

[00:00:00] Voiceover:  What do you say we get dialed in?

[00:00:18] Stefanie Bond, Communications Director: Welcome back everyone! We're back with a new episode and a new guest in our hot seat. Today I have with me Jeremy Ingram, and Jeremy, can you go ahead and introduce yourself and tell everyone what it is that you do at DIAL?

[00:00:30] Jeremy Ingrim, Bureau Chief: Sure. My name is Jeremy Ingrim, and I am the bureau chief of the Medicaid Fraud Control Unit. We're located in the Investigations Division, and I've been in the position for about eight and a half years now.

[00:00:40] Stefanie: Okay, so, yeah, you've been there for quite a while, so you know your stuff pretty well.

[00:00:44] Jeremy: I hope so.

[00:00:47] Stefanie:  So let's get started and talk about the basics. What exactly does the Medicaid Fraud Control Unit do? And why are you called a unit instead of a bureau? I mean, you are a bureau, but there's a reason why you're called the 'Medicaid Fraud Control Unit.'

[00:01:03] Jeremy: Yes, there's a little bit of conflict there. I am a bureau chief of a unit. So there's a Medicaid Fraud Control Unit in every state, along with Washington, D.C., Virgin Islands, and Puerto Rico. So there's 53 Medicaid Fraud Control Units throughout the country. We are 75% federally funded and HHS OIG, or the Department of Health and Human Services, the federal department, they pretty much give us that 75% grant every year whenever we reapply for it, and they refer to all the units as Medicaid Fraud Control Units. So...

[00:01:38] Stefanie:  It's a continuity thing.

[00:01:41] Jeremy: Yeah, there are other states that have changed their names and they've tweaked the names a little bit, but we're pretty much consistent with the rest of the country. Most of them are called Medicaid Fraud Control Units. There's even a National Association of Medicaid Fraud Control Units that we're a part of. And to be consistent with their acronym, NAMFCU, we pretty much go with the Medicaid Fraud Control Unit title as well.

[00:02:04] Stefanie: Or, what everybody here calls 'MFCU.'

[00:02:07] Jeremy: MFCU, yes, it's uh, we're not swearing at you when we say it.

[00:02:10] Stefanie: Right. Right. MFCU.

[00:02:12] Jeremy: It's a little it's a little bit of a weird acronym, yes.

[00:02:14] Stefanie: Well, you've only got the one vowel, so... 

[00:02:16] Jeremy: Yes.

[00:02:17] Stefanie: You just have to deal with it as you as you can.

[00:02:19] Jeremy: Yep.

[00:02:20] Stefanie: So that's great. So, before I started at DIAL, I wasn't aware that there was a Medicaid Fraud Control Unit in every state. Do you guys work together then, to do things, or, I mean, obviously you're going to do your, your thing in Iowa, but what kind of things do you work on together? Or are you collaborative with either the other states or just with the federal program?

[00:02:42] Jeremy: Yeah. So obviously, we do a lot of independent work here in Iowa involving Iowa Medicaid providers and abuse and neglect that occur in Iowa nursing homes and other long-term care facilities. Occasionally, we will have cases that may involve a provider who may be in Nebraska or South Dakota or even Illinois, you know, like a bordering state. And we may work with those Medicaid Fraud Control Units collaboratively, you know, because they might have a provider that's billing Nebraska and Iowa. We had a case several years ago in which an individual was defrauding Medicaid in Nebraska, in Iowa, and also Medicare. So we all worked collaboratively. It was Iowa Medicaid Fraud Control Unit, Nebraska and then our federal partners with the Department of Health and Human Services. That was a pretty complicated, complex case, but it had a good resolution, and we all worked together well.

[00:03:35] Stefanie: That's great. Not everyone knows the difference between Medicaid and Medicare. You just do Medicaid.

[00:03:42] Jeremy: Correct. We primarily do Medicaid. You know, they are not synonymous, obviously. I'm guilty of this myself. 

[00:03:46 ] Stefanie: Sure. 

[00:03:47 ] Jeremy: Before I joined the Medicaid Fraud Control Unit -- you kind of use Medicare and Medicaid interchangeably. But Medicare is completely, 100% federally funded, you know. And it's basically for people who are over the age of 65 and there's also people who are under the age of 65 that, meeting certain conditions that can be eligible for Medicare,

[00:04:08] Stefanie: Like someone on a dis -- with a disability?

[00:04:11] Jeremy: You know, like maybe a renal disease, I believe would be... 

[00:04:14] Stefanie: OK, sure.

[00:04:15 ] Jeremy: ...an example. Someone who's on dialysis might have eligibility for Medicare. 

[00:04:19] Stefanie: Okay.

[00:04:20] Jeremy: I'm not a real--

[00:04:21] Stefanie: You're not an expert on Medicare. Yeah.

[00:04:22] Jeremy: I'm not an expert in Medicare. I am the expert in Medicaid, though. No, I'm kidding, I'm not really the expert.

[00:04:26] Stefanie: More so than I am. 

[00:04:28] Jeremy: Well, I know a little bit more about Medicaid than Medicare myself, but, but Medicaid is more like, need based, you know, for individuals who are low income, disabled, maybe elderly individuals. And then also a big difference is that Medicaid is actually state and federally funded.

[00:04:44] Stefanie: So tell us about the types of fraud that you investigate. Like, give us some examples. Or how -- how do you hear about a case? How are those referred to you?

[00:04:57] Jeremy: Most referrals that we receive to conduct criminal Investigations -- they're sent to Iowa Medicaid from the managed care organizations. And then once Iowa Medicaid reviews and approves those referrals, then they are sent to the Medicaid Fraud Control Unit, and I can review that. And I can determine if there's a you know -- I look at a lot of different factors when I review the referral, probably one of the most important factors that I take into consideration is, you know, at the end of the day, if this allegation is true, is there really a likelihood for there to be a criminal prosecution for this? And and if so, then generally, I will open a case, and we will conduct our investigation. And if, if it seems to be more of like an administrative issue, you know, maybe it's just something that the provider might need more education, or maybe they just, you know, there's really no intent involved, that they were doing something intentionally to defraud Medicaid. 

[00:05:59] Stefanie: You just made a mistake.

[00:06:00] Jeremy. Correct. It might be something where, you know, we just decline it, and then the state Medicaid agency or the managed care organizations may go back and just recover the money through, like an administrative overpayment recovery process.

[00:06:15] Stefanie: Okay. So, for some people who don't understand what a managed care organization is, can you explain that a little bit?

[00:06:23] Jeremy: Sure. So back in 2016, the state of Iowa transitioned to a managed care model. So rather than the state administering the Medicaid program, um, there were some--they were basically private insurance companies that now administer the program. So I'd say probably about 95% of the Medicaid program is administered by the managed care organizations. And, you know, it's, I think there's probably two states in the country that do not implement the managed care model. So it's pretty much the most prevalent model out there. Um--

[00:07:08] Stefanie: It's the standard.

[00:07:09] Jeremy: Pretty much, yeah. There's--yeah, I'm pretty sure it's just two states now that still have more of a state-run Medicaid program without the implementation of managed care organizations.

[00:07:21] Stefanie: Well, I won't hold you to that if it's three. 

[00:07:23] Jeremy: (Laughs). Thank you. 

[00:07:25] Stefanie: So they, then, inform the state Medicaid agency, which is part of HHS?

[00:07:30] Jeremy: Yes. 

[00:07:31] Stefanie: Okay. And you work directly in hand in hand with HHS.

[00:07:36] Jeremy: Correct, yeah. So, Iowa Medicaid within HHS is kind of our liaison, you know? We, we have really good working relationships with Iowa Medicaid, their program integrity team, along with the managed care organizations. But we generally, you know, we may sometimes reach out and work directly with the managed care organizations if we have questions. But generally, a lot of our communications and a lot of our collaboration involve Iowa Medicaid and the managed care organization. So it's, it's a pretty much a team effort that we're--when we work with them, so...

[00:08:13] Stefanie: Sure. Okay, so you're--we were talking about criminal cases and how that works, because I don't think people understand, like, when we're investigating something, we don't ourselves prosecute it criminally.

[00:08:27] Jeremy: Correct. 

[00:08:28] Stefanie: So how does that work, then, to get a criminal prosecution if it comes to that? If it needs to be a criminal prosecution, how does that work?

[00:08:36] Jeremy: That's a great question. So here in Iowa, um, our investigators in the Medicaid Fraud Control Unit have peace officer status pursuant to Iowa Code. So that means that they do have the authority to go out and conduct criminal investigations. The only difference between our investigators and, you know, your, maybe local police officers or state DCI agents--not the only differences--but the main differences would be, we don't carry firearms and we don't arrest people. But other than that, we can go out and conduct criminal investigative activities. We can do surveillance. We file charges when authorized to do so by the county attorney. But in order for a case to be prosecuted, generally, we will conduct our investigation in whichever county the criminal offense occurred in. We will refer that case to that local county attorney's office. And, it's kind of up to them if they want to prosecute the case or not, and there are times their reasons being their own, they may not prosecute the case,. But generally, most of the time, when we refer a case and we recommend the applicable criminal charges, they will prosecute that case.

[00:09:53] Stefanie: Are there any instances where the county attorney would not be the one to prosecute and there would be another entity that would prosecute?

[00:10:01] Jeremy: Yeah, there's a couple examples. Sometimes we have cases that might reach a certain point that maybe a federal prosecution might be more applicable. And so we do have a really good working relationship with our partners in the Northern and Southern District--

[00:10:15] Stefanie: And that's in Iowa--just Iowa?

[00:10:16] Jeremy: Correct. Yes, yes. We can refer those cases to the Northern or Southern District for criminal prosecution. And then, rarely, we do have an assistant attorney general assigned to our office.

[00:10:29] Stefanie: She's embedded with you, right? Is that right?

[00:10:33] Jeremy: Correct. Yeah, she works exclusively on Medicaid Fraud Control Unit matters. And there have been rare occasions where we will refer a case for criminal prosecution to a county attorney's office, and there may be a conflict of interest, you know. Especially given the nature of our work, sometimes you might have a case involving a pharmacist in a rural county, and when you go and refer that case to the county attorney, that might be the county attorney's pharmacist.

[00:10:57] Stefanie: (laughs) Yeah, that would be a conflict.

[00:11:59] Jeremy: So, we do have the option that, at their request, our Assistant Attorney General can prosecute on their behalf. And that's happened once or twice that I can remember in the time I've been here. It's rare, but--

[00:11:10] Stefanie: Eight and a half years did you say?

[00:11:11] Jeremy: Yeah.

[00:11:12] Stefanie: Walk me through an investigation. What does that look like after you've been referred a case? Like, what--what are the different things that you might do? You mentioned surveillance, you mentioned investigating, but without the firearms or, um, the arrests. So what kind of things do you guys do on a regular basis, day to day?

[00:11:29] Jeremy: It kind of depends on the case. If we're investigating a fraud case, that can be a lot different than more of an abuse or neglect case that we might investigate in a nursing home or a long-term care facility. So for a fraud case, it's probably going to be very document-intensive. We'll be looking at a lot of claims data. We'll be getting a lot of other records that might be pertinent to the investigation. A prevalent type of case that we will work is a provider may be submitting claims for services that they're not actually providing to the members. And when we get those types of cases, we have the authority to get a lot of different records. You know, we'll get the records to see if we can prove that provider was somewhere else during the time frame, on the date and time that they say they were providing services to that individual. So just a lot of document evidence. And then sometimes we do have more covert capabilities that if we get an allegation, and it's something that we can maybe investigate more in real time, not historically, like going back and looking at previous claims to see if they were fraudulent. But maybe this is ongoing, and we can do some surveillance, or we can do some sort of other covert activity and confirm that they are not with the member, they are not providing services to this Medicaid member. And then when we can document those times and document their activities, and we can compare them later on to what they submit for claims, we've had a lot of cases where we've had successful case resolutions to show that, you know, they were not where they said they were when they billed Medicaid for these services.

[00:13:01] Stefanie: Wow, yeah. That's a lot of work, it sounds like, on you guys' end. How many people are in the Medicaid Fraud Control Unit?

[00:13:09] Jeremy:  Right now we are staffed at 11. So that would include seven investigators, we have an auditor, and we have an attorney, and we have myself as the bureau chief, and then we also have our paralegal. And some of those positions are actually federally required pursuant to our regulations. What?

[00:13:26] Stefanie: What, uh, what would you say the--the best part about your job is?

[00:13:30] Jeremy: I think the best part of my job--I have a law enforcement background. I was a police officer and I was a detective for 10 years before I joined the State. And, when I joined the Medicaid Fraud Control Unit as an investigator, initially, I was kind of, I kind of felt like I was just kind of a taxpayer watchdog.

[00:13:47] Stefanie: Mmm hmm.

[00:13:48] Jeremy: You know? But as I started working the cases, and I realized, you know, we're not just a watchdog for Medicaid dollars. But, I realized that, you know, a lot of people--last time I checked, close to 800,000 people in the state of Iowa depend on the Medicaid program--and just knowing that we are doing our part to make sure that the integrity of that program is maintained, and what we're investigating providers who are taking advantage of the program or exploiting the program, I think that satisfaction is probably my favorite part of the job. And then also just knowing that we have investigators going out and we're investigating abuse and neglect in the nursing homes and other long-term care facilities. We've seen so many examples where--I have to say this--the healthcare industry is just like any other profession, you know?: 99% of the individuals that are in this field are doing a fantastic job. They're taking fantastic care of their patients, but there is a very small percentage, just like any other profession, whether it be police officers or teachers, that they probably should not be in this line of work. And that's that's who we are dealing with in our office. And so I think there's a lot of satisfaction knowing that when we receive information indicating that somebody's caused harm to our vulnerable residents in these facilities or a patient in a hospital--you know, we can conduct an investigation and make sure they're held accountable for that. And then we can also make sure that, through the tools we have, if they're convicted of the crime as a result of our investigation, we can make sure that they don't ever get in a position to cause any more harm against anybody again.

[00:15:21] Stefanie: I think the part that people don't automatically see is the fact that you're investigating those abuses against those who are receiving Medicaid. So, the fraud and abuse.

[00:15:32] Jeremy: Also what's nice about our regulations is that even if you have a resident in a nursing home, they don't have to be a Medicaid beneficiary in order for us to investigate something. So just the fact that they're living in that nursing home, and it's most likely Medicaid-funded, that's kind of what gives us our authority to go in and conduct that investigation. So we have a lot of cases that involve non-Medicaid individuals, but they're living in a-- 

[00:15:56] Stefanie: Medicaid-funded facility. 

[00:15:59] Jeremy: Right. Just the fact that those facilities are receiving Medicaid dollars gives us the authority to go in and conduct those investigations.

[00:16:05] Stefanie: I imagine when you're doing those types of investigations that you're dealing with family members and friends of the abuse victims.

[00:16:11] Jeremy: We will contact them occasionally. I think they appreciate knowing that we're conducting an investigation. But you know, oftentimes these are pretty traumatic experiences, you know. And, we generally, we don't rely on the resident in those facilities to, you know, we don't have to have them verbally acknowledging that they want to pursue criminal charges. If we have indications that a crime has been committed against one of those residents, we're going in and we're going to look at it. And we'll tell the prosecutors at a later point--you know, we always keep them informed, you know, when it comes to a victim's willingness to cooperate or pursue charges. But you know, we've seen enough cases that generally, when--if this is happening to one person, it's probably happening to someone else. 

[00:16:56] Stefanie: Sure. 

[00:16:57] Jeremy: Um, and you know, we don't want to just put a vulnerable victim in that position of having to say, we want to pursue charges, because that makes them very vulnerable. They're already probably in a very vulnerable position where they're relying on these individuals to care for them, and they may not want to--

[00:17:17] Stefanie: Right.

[00:17:18] Jeremy: ...agree to pursue charges because they might fear that they're going to have a target on their back at that point.

[00:17:21] Stefanie:  So basically, you take that out of their hands so that that doesn't come back on them. That's you guys making that decision.

[00:17:27] Jeremy: Right. We don't put that burden on them. And sometimes, too, they may not have the mental wherewithal to--to make that decision. There might be individuals who are cognitively impaired due to dementia, or they might be in a memory care unit and again, you know, we're not going to rely on them for for that.

[00:17:46] Stefanie: Right. There's other ways to collect evidence, 

[00:17:47] Jeremy: Correct. If it's necessary for us to talk to a family member and get information. You know, obviously we will need to do that. Generally, family members are always very cooperative and appreciative of what we're doing. But if we can go in and we can leave as small of a footprint as we can without having to make the resident or family members relive any traumatic experience, then, you know, that's kind of one of our goals as well.

[00:18:11] Stefanie: So I imagine, because DIAL also does nursing home surveys, and we go into many other types of health care facilities--assisted living, etcetera--they receive complaints all the time, and I imagine some of those get passed on to MFCU. So you're working with that complaint unit and those surveyors hand in hand, to kind of deal with some of those complaints, to figure out if you're going to investigate.

[00:18:34] Jeremy: Correct. Probably 95% of our fraud referrals come from the managed care organizations and and Iowa Medicaid, and it's kind of the same with our abuse and neglect referrals. Probably 95% of those come from our Health and Safety Division here in DIAL. And just a side note: um, you know, I mentioned we have 53 Medicaid Fraud Control Units throughout the country. Almost all of them are located in their State's attorney general's offices. You know, we here in Iowa are very unique in that we're the only one located within a regulatory agency. And so I've always thought that there are pros and cons to that. But one of the big pros is that we've always had a fantastic working relationship with our Health and Safety Division, and we've had open lines of communications. We've been able to, you know, provide training to each other, to be able to--they know kind of what I'm looking for, you know, as far as what would make a good criminal investigation, or what what I'd like to look at to see if we need to go in and do a criminal investigation. And so I would say that's probably one of the huge benefits of being in the same agency as our state survey agency--would be just that communication that we have, and the that referral stream where we can just continue to get this information. And we may not be able to open every single referral we get, obviously. But you know, when we see these cases that, as I mentioned earlier, one of the biggest factors I look at is, if these facts are true, would a county attorney prosecute this person? Would there be a criminal prosecution? That's when I usually open the cases, when I feel confident that there was something that rose to the level of potential criminal prosecution.

[00:20:18] Stefanie: Because, yeah, there's a lot of things that they investigate, um, as part of a survey, whether it's a complaint survey or a regular recertification survey that might be a fineable offense, but it's not a criminal offense. So obviously they're not going to refer everything to you, but there are some things that have been egregious that they've obviously needed to send to you guys to investigate.

[00:20:40] Jeremy: Correct. 

[00:20:41] Stefanie: So do your investigators...is it like one investigator per case? Do you have multiple investigators sometimes working a case? How does that work? And how do they get assigned a case?

[00:20:51] Jeremy: Oh, that's great question. First of all, how they get assigned a case: We have investigators in our unit with a wide range of experience and preferences. You know, also, I think there's some investigators that just really feel passionately about certain cases, and I try to kind of use that, because--

[00:21:10] Stefanie: You're going to work harder on a case if you're more interested in it.

[00:21:13] Jeremy: Exactly. It's been my experience in law enforcement, and not only personally, but just if there's cases that you just do not like working, you know, you'll work it, but you're just not as-- 

[00:21:22] Stefanie: Invested.

[00:21:24] Jeremy: ...motivated, and. But if you have a case that you're passionate about: like, for example, we have investigators who are passionate about drug diversion cases--the theft of medications from residents in the facilities by the staff members taking care of them. And they've developed essentially, a very reputable expertise in those areas. So I want to use that experience and that expertise that they've gathered through the years working those cases. And so, a lot of those cases are going to go to specific investigators who love those cases and who are very good at them. I'm very fortunate to have a team that pretty much everything we need investigated, we have investigators that like those cases, love those cases and are very good at doing them--whether it be a fraud case, or a drug diversion case, or even just a neglect case where there was some sort of neglect committed against resident in a facility. The feedback I've gotten from my team is that pretty much everybody loves the types of cases that they're working and they're very motivated, and I couldn't ask for a better team right now, and who go out and get the job done.

[00:22:25] Stefanie: Well, Jeremy, I think we've had a really good session here today.

[00:22:29] Jeremy: Yes, I really enjoyed chatting with you about this.

[00:22:32] Stefanie: I appreciate it, because there's a lot that people don't know about Medicaid fraud and how it's handled, and so appreciate you coming in and kind of giving us some expertise on that.

[00:22:42] Jeremy: Well, it was my pleasure. And you know, we kind of like to work behind the scenes, and it's nice to be able to share kind of what we do and educate your listeners, s you know, kind of what our mission is. And we're going to keep working to keep Iowans safe.

[00:22:56] Stefanie: That's great. Thank you so much for joining us today. 

[00:22:58] Jeremy: Yeah. Thank you.