Senate Homeland Security and Governmental Affairs Subcommittee on Federal Financial Management, Government Information, Federal Services, and…
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Senate Homeland Security and Governmental Affairs Subcommittee on Federal Financial Management, Government Information, Federal Services, and International Security Hearing
Chairman Carper, Ranking Member Brown, and Members of the Subcommittee, thank you for the invitation to discuss the
The Administration has made important strides in reducing fraud, waste and improper payments across the government. Over the last two years, CMS has implemented powerful new anti-fraud tools provided by
Preventing and Detecting Fraud in the Federal Health Care Programs
CMS directly administers
The New "Twin Pillar" Strategy
CMS has implemented a twin pillar approach to fraud prevention in
The Medicaid Program
Preventing and Detecting Fraud in
States have primary responsibility for policing fraud, waste, and abuse in their
CMS is evaluating many of the tools used in
CMS is currently working to identify specific FPS algorithms applicable to
CMS is collaborating with our State partners to ensure that those caught defrauding
To support State efforts to share such information, CMS implemented a web-based application that allows States to share information regarding providers that have been terminated for cause and to view information on
CMS Collaboration with States on Medicaid Program Integrity
To address
Additionally, to provide effective support and assistance to States to combat
Through its reviews, CMS has identified 52 unduplicated program integrity "best practices" that we have publicized to all States through annual summaries of our efforts. The guidance includes specific examples of how States have created well-functioning and committed partnerships between the State Medicaid agency and its MFCU. CMS, working with State Medicaid agencies and MFCUs, issued guidance in
CPI is taking steps to improve communication and coordination on cross-cutting issues, which will strengthen program integrity efforts in both
Just recently, CMS announced another initiative to assist States in their program integrity efforts. On
CMS also provides States assistance with "boots on the ground" for targeted special investigative activities. Since
CMS Redesign of the National Medicaid Audit Program CMS has learned important lessons during the initial years of the Medicaid Integrity Program. Beginning in early 2010, CMS determined through internal analysis, environmental assessments, parallel discussions with stakeholders, and reviews of contractor performance that the initial auditing model of the Medicaid Integrity Program required fundamental changes to effectively support States in their efforts to combat fraud, waste, and abuse in their
The collaborative approach allows CMS to work alongside States in identifying areas that warrant further investigation and to develop the audit targets. Through this process CMS can more effectively support a State's program integrity efforts. In addition, the corresponding data for the collaborative audits is in many cases provided or supplemented by the States, making the data more complete and thus increasing the accuracy of any audit findings. The number of collaborative audits has progressively increased.
Since the earliest collaborative audits were assigned to Medicaid Integrity Contractors (MICs) in
CMS has continued to identify additional opportunities for program changes and improvement. CMS' redesign plan for the National Medicaid Audit Program recognizes the significant increase in
As noted earlier, others came to many of the same conclusions for the need for changes to strengthen
Both the OIG and GAO reports primarily focused on early results of the National Medicaid Audit Program and noted CMS' efforts to improve its program and expand collaborative audits with States appear to enhance results. In CMS' review of the relevant reports, including those from MACPAC and NAMD, we note there were similar recommendations, and we are pleased to note the Medicaid Integrity Program improvements CMS has initiated address many recommendations in those reports. Beyond the expansion of collaborative audits, examples include improving alignment of State and Federal audit activities, expanding support and training of State program integrity staff in vulnerable areas such as program integrity oversight of managed care and evolving integrated care models, facilitating development of State capacity and access to cost effective analytics technology, and providing guidance for better quantifying the effectiveness of program integrity activities to demonstrate impact of cost avoidance from prevention.
CMS is implementing the program redesign in a phased approach which involves piloting new concepts and sharing best practices with States, as well as collaborating with States to use State data directly for the National Medicaid Audit Program. These improvements include expanding reviews to managed care entities, refining the identification of audit targets like high-risk providers serving both
CMS is constructing an analytical approach that will assist States with their assessment of managed care rate setting. In addition, we intend to assess industry practices, share State best practices, and exchange ideas through the educational courses CMS sponsors at the
Improving Data to Fight Fraud in
CMS has made significant improvements to our databases and analytical systems in recent years. However, we acknowledge that more can be done. CMS is committed to enhancing the quality and availability of our data to States. CMS is keenly aware that States' appropriate access to
Additionally, CMS recently launched an initiative to transform the agency's approach to data and analytics.
Integrated Data Repository (IDR)
CMS has made great progress in building the Integrated Data Repository (IDR) to provide a comprehensive view of
The IDR continues to be an integral part of CMS' data strategy. The IDR ensures a consistent, reliable, secure, enterprise-wide view of data supporting CMS and its partners in more effective delivery of quality health care at lower cost to CMS' beneficiaries through state-of-the-art health informatics.
CMS is also working to incorporate State Medicaid data into the IDR, while also working with States to improve the quality and consistency of the data reported to the Federal government from each State. MSIS data has been the primary data source for
* Promoting consistent leadership on key challenges facing State health programs;
* Improving the efficiency and effectiveness of the Federal-State partnership;
* Making data on
* Reducing duplicative efforts within CMS and minimizing the burden on States.
The Council has initiated several efforts including the Transformed MSIS (T-MSIS) pilot project in 11 States, which together represent 40 percent of the nation's
One Program Integrity (One PI)
Improved data and analytical tools will allow CMS and its partners to analyze information from throughout the claims process to identify previously undetected indicators of aberrant activity. Used with the IDR, CMS' One PI web-based portal, and analytic tools helps CMS share data with our integrity contractors and law enforcement and enhances their use of the data. CMS has been working closely with our law enforcement colleagues to provide One PI training and support. Since October of 2010, CMS has provided training at CMS's Baltimore Training Facility to a total of 622 program integrity contractors and CMS staff, including 82 law enforcement personnel, on the portal and tools on One PI.
The Medicare-Medicaid Data Match Program
The Medicare-Medicaid Data Match Program (Medi-Medi) is another CMS initiative to improve the use and availability of better quality
CMS is working to identify ways the Medi-Medi program can be improved and made more beneficial to States. We are also exploring additional opportunities to collaborate with States as well as working directly with States to match
Looking Forward
As these efforts mature, we expect to be able to more easily transfer the lessons learned from
n1 Medicaid Integrity Institute FY-12 Training Calendar: http://www.justice.gov/usao/eousa/ole/mii/mii.courses.12.pdf
n2 MSIS data is the primary data source for
n3 http://www.cms.gov/Regulations-and-Guidance/Legislation/DeficitReductionAct/Downloads/fy10rtc.pdf; page 24.
n4 HHS OIG, "Early Assessment of Audit Medicaid Integrity Contractors."
n5 MACPAC, "Report to the
n6 NAMD, "Rethinking Medicaid Program Integrity: Eliminating Duplication and Investing in Effective, High-Value Tools."
n7 GAO. "
Read this original document at: http://www.hsgac.senate.gov/download/?id=3098ad8d-82f4-4b79-ad4c-cb0b60c2ef6c
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