The Council of State Governments – Innovations Award July 20, 2012 – Atlantic City, NJ

The Council of State Governments – Innovations AwardJuly 20, 2012 – Atlantic City, NJ

Gary D. AlexanderSecretary, PA Department of Public Welfare

Agenda

About Pennsylvania’s Department of Public Welfare

The Case for Change

Program Integrity (PI) Initiative

2012 Program Integrity Priorities

PI Process Improvements, Technology Initiatives, and Organizational Changes

Program Integrity Results

Transferability

Questions and Discussion

Enterprise Program Integrity – Gary D. Alexander, Secretary, PA Department of Public Welfare

Page – 2

About Pennsylvania’s Department of Public

Welfare

Page – 3

One in every 4.6 Pennsylvanians receives some form of welfare assistance

1Unduplicated number of persons receiving assistance that includes DPW assistance programs plus the Children’s Health Insurance Program (CHIP) as of May 2012.

Pennsylvania’s 2010 Census Population: 12.7 millionPennsylvanians receiving assistance:1 2.75 million


Page – 4Enterprise Program Integrity – Gary D. Alexander, Secretary, PA

Department of Public Welfare

About Pennsylvania’s Department of Public

Welfare

The Case for Change

Page – 5

Challenges Pennsylvania Faced:

Legislative mandate to reduce fraud, waste, and abuse

Auditor General issued audits of benefit programs that highlighted fraud, waste, and abuse

Significant budget cuts; forced to do more with less

Increased pressure from internal and external stakeholders to improve transparency and accountability


Page – 6

Program Integrity Initiative

July 2011 to October 2011


Page – 7



As-Is Gap Analysis To-Be




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Person-Centered

Integrated

Fiscally Responsible

Accountable

Guiding Principles Program Integrity Objectives Performance Outcomes

Increase consistency in collecting, sharing, and analyzing useful information across multiple program offices to proactively minimize the potential for fraud, waste, and abuse and support effective decision making.

Operate the most cost-effective welfare program possible by proactively evaluating, delivering, and paying for the highest quality services based on best value and verified need.

Hold providers, recipients, retailers, and employees accountable for understanding and complying with stated program requirements.

• Improved data integrity• Increased efficiencies• Improved predictability

• Reduced non-compliance• Increased transparency

• Improved payment accuracy• Improved return on investment• Reduced inappropriate services• Increased rate consistency• Improved recovery efforts• Reduced service excess


2012 Program Integrity Priorities

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Increase overpayment referrals and recoveries

Improve quality control processes

Strengthen application intake controls

Streamline fraud referral processes

Enhance provider accountability

Focus program integrity performance measures to drive decision making

Implement information technology solutions that target front-end detection


PI Process ImprovementsNovember 2011 to Present

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Prevention-Based

Enhanced overpayment identification process

Risk-based case review process

Standardized criteria for evaluating provider applicants

Provider and recipient overlap

Standardized process for vehicle Special Allowance requests


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Detection-Based

Backlogged case review

Risk-based quality control process

State and Federal benefit data match

Provider audits

Audits/monitoring of Office of Children, Youth, and Families funding

Centralized fraud referrals

Reviewing One-Time Issuances

Streamlined overpayment referral process

EBT card reviewsEnterprise Program Integrity – Gary D. Alexander, Secretary, PA

Department of Public Welfare

PI Process ImprovementsNovember 2011 to Present

PI Technology InitiativesJune 2012 to Present

Page – 12

Enhanced use of data exchanges

Prioritized alerts and automated data exchange hits

Centralized scanning and imaging (COMPASS)

Increased accessibility (COMPASS)

Repository of Abuse and Fraud Tracking System (RAFTS)

Real-time fraud scoring engine

Strengthening One-Time Issuance and sanction rules

Executive Dashboard (PI performance measures)

Front-end/pre-payment data analytics and fraud detection


PI Organizational ChangesNovember 2011 to Present

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Program Integrity Office

Program Integrity Units in County Assistance Offices (CAOs)

Collaboration with the Office of Inspector General (OIG):

Overpayment referrals and recoveries Application investigations Fraud investigation program SNAP trafficking Enhancing OIG content in caseworker training Reestablished OIG role in CAOs



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Backlogged Case Review: 385,958 backlogged cases 88% reviewed in SFY 12 resulting in 30% case closures

State and Federal Benefit Data Match: 6,609 potential matches 34% proved to be unknown income $3,584,868 amassed in cost avoidance with potential to

increase through overpayment recoveries

EBT Card Reviews: 1,123 cases identified with non-continuous, out-of-state

electronic benefit transactions 58% of identified cases have been closed $927,107 amassed in cost avoidance


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Provider and Recipient Overlap: 2,700 cases identified with provider/recipient overlaps Child care payments not identified as income

OIG Recipient Cost Recoveries and Avoidance: $38,840,063 costs recovered in SFY 12 $72,929,360 costs avoided in SFY 12

Bureau of Program Integrity (BPI) Provider Cost Recoveries and Avoidance:

$15,375,974 costs recovered in SFY 12 $34,356,000 costs avoided in SFY 12 (Managed Care

Organization recoveries and recipient restrictions)



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Medical Assistance (MA) Recipient Overpayments and Recoveries:

153 MA overpayments referred to OIG $230,450 ($1,506 per referral) in overpayments referred

Third Party Liability (TPL) Cost Recoveries, Savings, and Avoidance:

$148,208,641 costs recovered (casualty, health insurance, and estate recoveries)

$101,527,166 costs saved through the HIPP program $338,166,235 costs avoided through health insurance

utilization

Bureau of Finance and Operations Audits: $1,070,560 costs recovered through provider audits $12,300,000 costs avoided through provider audits



Transferability

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Program integrity framework is designed to support unique needs

Encompasses organization, process, technology, policy, and performance measures

Supports tactical (short-term) and strategic (long-term) planning and execution

Driven by environment-specific risks – tailored approach recognizing that one size does not fit all

Extensible to support program office, department, or state level


The Council of State Governments – Innovations AwardJuly 20, 2012 – Atlantic City, NJ

Gary D. AlexanderSecretary, PA Department of Public Welfare

The Council of State Governments – Innovations Award July 20, 2012 – Atlantic City, NJ

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Transcript of The Council of State Governments – Innovations Award July 20, 2012 – Atlantic City, NJ