The Challenges of Obamacare for Medicaid Provider Enrollment Staff

1. The Challenges of Obamacare for Medicaid Provider Enrollment Staff A Capstone Project by Dale Elder Portland State University Executive Master of Public Administration Mark O. Hatfield School of Government Advisor: Dr. Gary Larsen June 15, 2013

2. Cowboy Logic “it’s far easier to make sure the gate is closed than it is to round up the cows after they’d gotten out.” - Grandpap Elder

3. Patient Protection & Affordable Care Act (ACA) of 2010 • Uses existing health industry structure • Insurance based – Industry & AMA Support • Provisions to “fix” existing fraud & abuse issues • Section 6401 – Provider Screening & Enrollment • New “gatekeeper” model – Cowboy Logic • License verification • Site visits • Databases: LEIE, MED, EPLS, SSN Master Death File

4. Department of Health and Human Services (HHS) February 11, 2013News Release A record $4.2 billion in Medicare and Medicaid fraud and abuse was recovered in 2012 “The administration is also using tools authorized by the ACA to fight fraud, including enhanced screening and enrollment requirements, increased data sharing across government, expanded recovery efforts for overpayments and greater oversight of private insurance abuses”

5. GREAT! But……that’s only 1.4% of the 2011 Estimated Annual Loss Amount

6. Since the ACA – An average increase of 44% over the previous 2010 $2.86 billion record was recovered in 2011 and 2012

7. Leadership Challenges • Each State at different levels of implementation • Gaining the authority to act • Overcoming the lack of tools or access to the tools • Bureaucracy of the Oregon Health Authority • Lack of staff and budget resources • The “ostrich effect” • “But we’ve always done it that way”

8. Leadership Solutions • Form strategic intent • Self education and team consensus on future state • Orchestrate Change • Communicate, communicate, communicate • Build understanding in both internal and external stakeholders • Implement the necessary operational changes • Form Strategic Alliances • Share with other States • Change / Learn the New Operational Environment • Implement necessary changes and adjust as necessary • Measure and Strengthen the Foundation • Use data to support future course corrections

9. Questions?

10. THANK YOU! • All of my fellow cohort members and their families – without their support and encouragement – I may not have finished • The outstanding faculty and staff of the Mark O. Hatfield School of Government at Portland State University – he would have been proud • “Super Yachi”, Davis and Marcy – for the behind the scenes coordination and we have pictures!