April 2015 Sunset Review of Washington’s Medicaid Fraud False Claims Act Proposed Scope & Objectives Mark Fleming, JLARC Staff

Washington participates in the federal Medicaid program  Program pays health care providers for services to eligible low income individuals and families  $11.8 billion  In some instances providers file false claims, using a variety of fraudulent schemes, including:  Billing for services not provided  Billing for unnecessary services  Misrepresenting services rendered or product provided  Creating false records to support claim for payment April 2015Sunset Review of Washington’s Medicaid Fraud False Claims Act2/8

Federal Government uses federal false claims act to recover fraudulent payments  Recoveries are shared with the states  Has encouraged states participating in Medicaid program to enact false claims statutes  Washington enacted a false claims act in 2012 April 2015Sunset Review of Washington’s Medicaid Fraud False Claims Act3/8

Act authorizes Attorney General’s Office to pursue Medicaid fraud through civil action Pursued criminal fraud cases Reported fraud to Attorney General Pursues civil fraud cases (as well as criminal) Can initiate civil fraud cases Reviews cases initiated by Whistleblowers Can pursue fraud cases AG has declined Attorney General Whistle- blowers Medicaid Fraud False Claims Act Enacted 2012Expires June 30, 2016 unless reauthorized by Legislature Attorney General Whistle- blowers Declines case Accepts case prior to 2012 April 2015Sunset Review of Washington’s Medicaid Fraud False Claims Act4/8

State and Federal false claims acts work in conjunction  Federal actions target multi-state schemes  Washington actions target state providers  Beyond civil authority, Washington’s false claims act enables AG to:  Participate directly in federal false claims investigations involving Washington providers  Obtain 75% federal match for civil unit funding  Receive additional 10% share of federal recovery amounts April 2015Sunset Review of Washington’s Medicaid Fraud False Claims Act5/8

Since Washington’s FCA was enacted, AG reports $76 million in recovered funds  Primarily result of 147 federal false claims actions involving Washington providers  Recoveries divided almost equally between state and federal government  State share of recovered funds is deposited in the Medicaid Fraud Penalty Account  May be appropriated only for specified uses, including Medicaid program services and AG Medicaid Fraud Control Unit April 2015Sunset Review of Washington’s Medicaid Fraud False Claims Act6/8

Sunset Review Questions 1.Has use of the Medicaid Fraud False Claims Act complied with legislative intent? 2.Does the Act provide for efficient and economical oversight of Medicaid providers, with adequate cost controls in place? 3.Have actions pursuant to the Act achieved expected performance goals and targets? 4.Does the Act duplicate the activities of another agency or the private sector? April 2015Sunset Review of Washington’s Medicaid Fraud False Claims Act7/8

Next Steps and Contacts Preliminary ReportSeptember 2015 Proposed Final ReportDecember 2015 Mark Fleming, Project Lead Valerie Whitener, Project Supervisor