Beyond those direct recoveries, Optum estimates $1.7 billion in potential improper payments over the 46-month period tied to vague rules and policy loopholes that failed to limit billing or trigger automatic system edits.
According to the report, clearer rules and stronger pre-payment controls could have prevented much of that exposure.
“These vulnerabilities stem from weakness in monitoring, auditing, and inter-agency communication, which undermine program integrity,” the report stated. “Such gaps can result in beneficiary harm, improper payments, eligibility errors, or intentional fraud, waste, and abuse, for example, billing for services never provided or delivering unnecessary care that leads to inefficient resource use. These issues often arise from exploiting policy loopholes or inconsistent interpretations of policy.”
During an online press conference, KARE 11 Investigates asked DHS leadership why outside analysts were able to identify vulnerabilities in just 90 days that the state had not flagged over several years.
Minnesota Medicaid Director John Connolly acknowledged the agency lacked adequate tools to keep up with increasingly complex billing schemes.
“We did not have tools up to the task of responding to the increasingly complex fraud schemes that we have been grappling with,” Connolly said.