Doug Porter Assistant Secretary, Medicaid Purchasing Administration, Washington State
National Health Reform – a double‐sided coinSizing the ProblemFederal Requirements/State ObligationsFederal initiatives–There’s a lot going on!
Pre‐President ObamaWhat’s new under President Obama? Even More!What’s new from Congress?
State ConcernsHow can CMS address state concerns?What’s a responsible Medicaid Director to do?
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National Health Reform brings opportunity to states to maintain existing coverage, expand coverage and eventually ensure universal coverage.However, for those upon whom much has been bestowed, much is expected.The flip side of the expanded coverage coin is enhanced Medicaid Payment Integrity
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Depends on what’s countedFraud – is the smallest portion of IPsAbuse – is the next bucket“Waste” is a huge catch‐all depending on what’s included
Unintentional errors/honest overpayments?Coverage to ineligible clients?What about purchasing healthcare that doesn’t work?What about eligible clients denied coverage?Provider Underpayments?
PERM’s error rate is misleading4
State Program Integrity EffortsGoverned by federal regulations at 42 CFR 433 – Discovery and Repayment of Provider Overpayments; 42 CFR 455 –Medicaid Program Integrity; 42 CFR 1001 – Program Integrity in Medicare and State Health Programs; 42 CFR 1002 – Exclusions; 42 CFR 1007 – State Medicaid Fraud Control Unit:
Each state Medicaid program is required by federal rule to have a Surveillance and Utilization Review System (SURS)
▪ Usually housed within the Medicaid Program Integrity organization▪ Identifies/refers and audits for Medicaid overpayments caused by “fraud, waste, and
abuse”▪ Suspected fraud must be referred to the Medicaid Fraud Control Unit (MFCU)▪ Waste and abuse usually addressed through the state’s administrative processes▪ Automated claims processing and retrieval system
Method to verify with recipients that services were providedProvider Enrollment
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National Programs and Initiatives
Deficit Reduction Act (DRA), Section 6034, 42 U.S.C. Section 1396 U‐6Establishment of the Medicaid Integrity Group▪ Support and Assistance to States (MII)▪ Establishment of the Medicaid Integrity Contractors (MICs)▪ Provider Education
Other federal initiatives funded under the DRA▪ Office of the Inspector General Auditors▪ Payment Error Rate Measurement (PERM) program created under the Improper Payment
Information Act of 2002▪ Medicare/Medicaid or “Medi‐Medi” program
Other Federal oversight of the Medicaid Program (outside of the DRA)State AuditorsRecovery Audit Contractors (RACS) established under the Medicaid Modernization Act of 2003 and the Tax Relief and Healthcare Act of 2006Zone Program Integrity Contractors (ZPICs)Rapid Response Teams (RRTs)Medicaid Fraud Control Units within state Offices of Attorneys General
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President Obama’s Executive Order No. 13520, November 23, 2009A ll agencies of the federal government “must make every effort to confirm that the right recipient is receiving the right payment for the right reason at the right time” and intensify its efforts “to eliminate payment error, waste, fraud, and abuse” in government programs.
President Obama’s BudgetPlaces renewed emphasis on preventing, detecting, and recouping fraudulent, wasteful, and abusive payments in Medicare/ Medicaid/CHIP ‐Additional ‐$250 million
First Annual National Healthcare Fraud Summit – Jan. 2009The National Summit features discussions of innovative ways to eliminate fraud and abuse in the U.S. health care system – not limited to Medicaid.
Created New Center for Program Integrity – March 2009Dr. Peter BudettiCombines Medicare and Medicaid PI
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Congress passes the Improper Payment Elimination and Recovery Act – March 2010“In 2009 taxpayers lost $98 billion in wasteful improper payments…with $54 billion coming from Medicare and Medicaid.”
Payment Protection and Affordable Care Act – PI Provisions
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State budgets and cost of unfunded mandatesCoordination and training burden across many federal contractors causing loss of state savings and return on investment60‐day rule – better nowPERMLack of 75/25 fundingCMS plans being implemented without much state participation in order to meet tight timelinesStates who have a poor history of PI “win”Access ‐ as these efforts are “on top of” payment reform and evidence based purchasing
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Fund states appropriately to comply with new federal expectationsBetter outreach and education of providersResolve SDW /TPL issue with SSAImplement National CredentiallingOverhaul PERM program
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Care about Medicaid Program IntegrityKnow the moving pieces and requirementsStrategically take advantage of federal resourcesKeep lines of communication with providers open – you may need to intervene with CMSStress coordination and collaboration across the many federal entities asking for data and auditing providers
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Doug Porter Assistant Secretary
Medicaid Purchasing AdministrationState of Washington626 8th Avenue, SE
P.O. Box 45502Olympia, WA 98502-5504
Tel: 360.725.1040Fax: 360.586.9551