Alliance for Health Reform Panel Briefing

1. Alliance for Health ReformPanel Briefing Doug Porter, Medicaid Director Director, Health Care Authority March 5, 2012

2. 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

3. Washington State Results PRP assumed one-time historical overpayment recovery for Medicare/ Medicaid dual eligible clients PRP Savings Trend, SFY 2000-2011 • 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 $20.2 m $16.4 m $13.9 Change over to new ProviderOne and FADSystems $9.3 m $8.3 m $6.9 m $5.2 $5.1 m $4.8 m $3.2 m $2.0 m $0.1 m __________________________________ STATE FISCAL YEAR __________________________________

4. State 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

5. Recommendations • 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)

6. More 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

7. Questions? Doug Porter, State Medicaid Director Director, Health Care Authority 360.725.1040 Doug.porter@hca.wa.gov