April 2015 Sunset Review of Washington’s Medicaid Fraud False Claims Act Proposed Scope &...
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April 2015 Sunset Review of Washington’s Medicaid Fraud False Claims Act Proposed Scope & Objectives ark Fleming, JLARC Staff
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Transcript of April 2015 Sunset Review of Washington’s Medicaid Fraud False Claims Act Proposed Scope &...
April 2015
Sunset Review of Washington’s Medicaid Fraud False Claims Act
Proposed Scope & Objectives
Mark Fleming, JLARC Staff
Sunset Review of Washington’s Medicaid Fraud False Claims Act
Washington participates in the federal Medicaid program Program pays health care providers for services
to eligible low income individuals and families $11.8 billion 2013-15
In some instances providers file false claims, using a variety of fraudulent schemes, including: Billing for services not provided Billing for unnecessary services Misrepresenting services rendered or product
provided Creating false records to support claim for
paymentApril 2015 2/8
Federal Government uses federal false claims act to recover fraudulent payments Recoveries are shared with the states
Has encouraged states participating in Medicaid program to enact false claims statutes
Washington enacted a false claims act in 2012
April 2015Sunset Review of Washington’s Medicaid Fraud False Claims Act 3/8
Act authorizes Attorney General’s Office to pursue Medicaid fraud through civil action
Pursued criminal fraud cases
Reported fraud to Attorney General
Pursues civil fraud cases (as well as criminal)
Can initiate civil fraud cases
Reviews cases initiated by Whistleblowers
Can pursue fraud cases AG has declined
Attorney General
Whistle-blowers
Medicaid Fraud False Claims Act
Enacted 2012 Expires June 30, 2016unless reauthorized by Legislature
Attorney General
Whistle-blowers
Declines case
Accepts case
prior to 2012
April 2015Sunset Review of Washington’s Medicaid Fraud False Claims Act 4/8
State and Federal false claims acts work in conjunction Federal actions target multi-state schemes
Washington actions target state providers Beyond civil authority, Washington’s false claims
act enables AG to: Participate directly in federal false claims
investigations involving Washington providers Obtain 75% federal match for civil unit funding Receive additional 10% share of federal recovery
amounts
April 2015Sunset Review of Washington’s Medicaid Fraud False Claims Act 5/8
Since Washington’s FCA was enacted, AG reports $76 million in recovered funds Primarily result of 147 federal false claims
actions involving Washington providers Recoveries divided almost equally between state
and federal government State share of recovered funds is deposited in
the Medicaid Fraud Penalty Account May be appropriated only for specified uses,
including Medicaid program services and AG Medicaid Fraud Control Unit
April 2015Sunset Review of Washington’s Medicaid Fraud False Claims Act 6/8
Sunset Review Questions
1. Has use of the Medicaid Fraud False Claims Act complied with legislative intent?
2. Does the Act provide for efficient and economical oversight of Medicaid providers, with adequate cost controls in place?
3. Have actions pursuant to the Act achieved expected performance goals and targets?
4. Does the Act duplicate the activities of another agency or the private sector?
April 2015Sunset Review of Washington’s Medicaid Fraud False Claims Act 7/8
Next Steps and Contacts
Preliminary Report September 2015Proposed Final Report December 2015
Mark Fleming, Project [email protected] 360-786-5181
Valerie Whitener, Project [email protected] 360-786-5191
www.jlarc.leg.wa.gov
