Alliance for Health ReformAlliance for Health ReformPanel BriefingPanel Briefing

Doug Porter, Medicaid DirectorDirector, Health Care AuthorityMarch 5, 2012

Update from the front line…Update from the front line…• States strongly commit to ensuring accurate

payments and prevention of fraud, waste and abuse

• States must ensure all dedicated resources produce a positive return on investment

• States increasing in sophistication of data mining and deployment of technology

• Balancing maintenance of existing effort and meeting new requirements, including coordination with federal effort

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$13.9

$20.2 m

$8.3 m

$9.3 m

$6.9 m

$5.1 m

$3.2 m

$2.0 m

$0.1 m

PRP assumed one-time historical overpayment recovery for Medicare/

Medicaid dual eligible clients

$16.4 m

$4.8 m

__________________________________ STATE FISCAL YEAR __________________________________

PRP Savings Trend, SFY 2000-2011

$5.2

Washington State ResultsWashington State Results

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• Installed its second generation Fraud and Abuse Detection System

– Highlights: enhanced algorithms and models, focus on managed care, ability to use external data sources for review

• New State-of-the-art MMIS introduced advanced edit/audit capabilities

• Taking advantage of Recovery Audit Contractors per ACA requirement

• Over $95 million recovered to date

Change over to new ProviderOne and FAD

Systems

State ConcernsState Concerns• Preserving existing recovery rates while

redeploying resources to coordinate with federal efforts that do not generate a positive ROI (recent OIG report on MIC audits state what states told CMS from the beginning – MSIS data won’t work)

• States received $0 under the DRA or the ACA to enhance efforts or cover new costs

• States received lowest match rate for PI – where MFCUs received 75/25 match

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RecommendationsRecommendations• Federal efforts should do what states don’t do

– Interstate activity– Control access at the beginning through issuance of NPI

as level one to provider enrollment– Cross reference federal data sets from Medicare, DEA,

NPI for data mining (as states lack access)

• Stop or fix initiatives that don’t work– PERM– Medi-Medi– MICs

• Support states through better funding (better match rate and allow states to apply for grants)

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More RecommendationsMore Recommendations• Beware of unintended consequences – example

Small Business Jobs Act

• Enforce program integrity standards on the industry (as health care PI is larger than Medicare and Medicaid), but also on Medicaid managed care plans – ACA gave a “pass” to MCOs on enhanced provider

screening requirements and the requirement that referring, ordering and prescribing providers be Medicaid enrolled (and screened)

– State must implement RAC for FFS but may implement RAC for managed care

– Have “forethought” about PI in the age of payment reform

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Questions?Questions?

Doug Porter, State Medicaid DirectorDirector, Health Care Authority360.725.1040Doug.porter@hca.wa.gov

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