Transcript Doug Porter`s Presentation

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
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Washington State Results
PRP Savings Trend, SFY 2000-2011
$20.2 m
PRP assumed one-time historical
overpayment recovery for Medicare/
Medicaid dual eligible clients
$16.4 m
$13.9
$9.3 m
$8.3 m
$6.9 m
$5.1 m
Change over
to new
ProviderOne
and FAD
Systems
$5.2
$4.8 m
$3.2 m
$2.0 m
$0.1 m
__________________________________ STATE FISCAL YEAR __________________________________
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• 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
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
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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)
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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
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Questions?
Doug Porter, State Medicaid Director
Director, Health Care Authority
360.725.1040
[email protected]
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