Alliance for Health Reform Panel Briefing Doug Porter, Medicaid Director Director, Health Care Authority March 5, 2012

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 2

$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 $5.2 Washington State Results 3 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 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 wont 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 4

Recommendations Federal efforts should do what states dont 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 dont work – PERM – Medi-Medi – MICs Support states through better funding (better match rate and allow states to apply for grants) 5

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 6

Questions? Doug Porter, State Medicaid Director Director, Health Care Authority