New York Fraud, Waste and Abuse, Recovery and Detection Project

1. New York Fraud, Waste and Abuse, Recovery and Detection Project A Strategic Partnership to Increase Program Integrity

2. Introductions James G. Sheehan, Medicaid Inspector General, State of New York William S. Fox, J.D., M.A., Vice President MAXIMUS Anne C. Chappuie, M.H.A., Vice President MAXIMUS David M. Paul, C.P.A., C.F.E, Director MAXIMUS

3. Our Solution: A Strategic Partnership Embraces a shared vision to generate significant taxpayer savings and reduce inaccurate billing practices Combines State program policy experts with leading industry specialists and cutting-edge technology to create customized algorithms and unearth significant overpayment recoveries Aligns incentives to successfully attain our vision and create the model Medicaid Integrity Program

4. The New York State Medicaid Program $46 billion program New York State accounts for 7% of the U.S. population and accounts for nearly 14% of Medicaid funds nationwide Highest per capita Medicaid expenditure in the country Per capita New York Medicaid spending is 130% more than the national average $10,000 per recipient

5. F-SHRP is a waiver program to reform and restructure the State�s healthcare system and to ultimately promote the efficient operation of that system. Under F-SHARP, CMS invests a total of $1.5 billion over 5 years in reform initiatives. Federal funding is subject to conditions and milestones that must be met by the State by the end of the five year demonstration period. If the State does not meet the targets in any of the years, it will be required to pay the Federal government an amount stipulated in the waiver for that particular year. Federal-State Health Reform Partnership (F-SHRP): An Overview

6. F-SHRP: Conditions and Milestones

7. The Inception of OMIG In 2004, The New York Times began addressing accounts of fraud through an analysis of data obtained under The Freedom of Information Law. The series of articles showed instances of fraud, waste and abuse activities of both health care providers and enrollees. In November 2006, the New York OMIG was created as a formal state agency to conduct and supervise activities to prevent, detect and investigate Medicaid fraud, waste and abuse

8. OMIG Program Integrity Vision: A Three-pronged approach

9. Compliance �We want to make New York a program integrity model by working with health care providers on compliance programs, and working with our agency partners to assure that payment rules are clear, fair, and easy to identify. � �We want to help make New York the State that �puts patients first� by focusing on information, quality and patient outcomes in our work as well as compliance with payment rules, and by working with our agency partners to assure that Medicaid providers meet minimum standards, or cease to be paid for Medicaid services to our patients.�

10. Compliance: Common Concerns Is an ineffective, non-compliant compliance program a program? Should an effective compliance program have discovered matters identified by OMIG audit or investigation? Mandated compliance programs-is this a health care version of �principles-based regulation� (vs. rules-based regulation) now being advocated in financial sector Significant differences between traditional Sentencing Guidelines model and New York mandated model

11. Compliance: Components

12. Compliance: Professionally Recognized Standards

13. Compliance: Functions in Meeting Professional Standards

14. Compliance: Quality and Enforcement

15. Audits and Recoveries Conducts audits and reviews of Medicaid providers to ensure compliance with program requirements, including quality of care, and to determine the amount of any overpayments made Numerous field audits for SFY 2008 � 09 Key areas of focus include HMOs Skilled Nursing Facilities Hospitals Ambulatory Surgery Services Assisted Living Facilities Diagnostic and Treatment Centers Durable Medical Equipment Home Health/Personal Care Services MAXIMUS is an integral component of the SFY 2008 � 09 workplan and is identifying significant new recovery opportunities

16. MAXIMUS: Helping Government Serve the People� Premier government services provider for over 30 years Over 5,500 employees in 280 offices nationwide and internationally Healthy financial condition � NYSE traded company with strong balance sheet Serving over 4,000 U.S. government clients All 50 states, the District of Columbia, Puerto Rico, the Virgin Islands, Canada, Australia, and Israel Every major U.S. county and city Federal government agencies and departments � including CMS

17. MAXIMUS: Experience MAXIMUS Offers a Wide Range of Health and Human Services Solutions

18. MAXIMUS: NYFWARD Accomplishments

19. MAXIMUS: NYFWARD Accomplishments continued Evaluating current FWA activities, pre- and post-payment reviews, and technologies utilized through data mining and analysis Identifying new initiatives to detect and prevent improper payments Estimating possible savings, costs, and time Implementing new improvements and initiatives approved by the State and assisting New York in changing current processes in order to improve recoveries and cost avoidance

20. MAXIMUS: NYFWARD Accomplishments continued

21. MAXIMUS: NYFWARD Accomplishments continued

22. MAXIMUS: Accomplishments continued

23. MAXIMUS: Accomplishments continued

24. MAXIMUS: Accomplishments continued

25. MAXIMUS: Lessons Learned Define respective project goals Chart a common path to success encompassing respective goals Engender a collaborative environment

26. MAXIMUS: NYFWARD Approach Data Integrity Budgets and Resources Creativity of Providers and Suppliers Belief That �This Can�t Happen in Our System�

27. MAXIMUS: Program Integrity Solution

28. Conclusion Through this collaborative approach to enhancing fraud, waste and abuse, recovery and detection efforts in the State of New York, both MAXIMUS and OMIG are strategically aligned to successfully attain our project goals and create a model Medicaid Integrity Program

29. The Future of Program Integrity Prevention vs. Collection Education and Training Stakeholder Commitment Real Compliance Comprehensive Program Integrity Programs Push Data Mining to the front Integration of State, Federal and Provider Efforts

30. The Future of Program Integrity continued Data analysis (by both providers and agency) will drive program integrity Never events, highly improbable events, and series of events Systems and controls at larger providers and MCOS-share prevention duties Still significant role for clinically supported audits and investigations

31. Questions