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
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About Pennsylvania’s Department of Public
Welfare
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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
Enterprise Program Integrity – Gary D. Alexander, Secretary, PA Department of Public Welfare
Page – 4Enterprise Program Integrity – Gary D. Alexander, Secretary, PA
Department of Public Welfare
About Pennsylvania’s Department of Public
Welfare
The Case for Change
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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
Enterprise Program Integrity – Gary D. Alexander, Secretary, PA Department of Public Welfare
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Program Integrity Initiative
July 2011 to October 2011
Enterprise Program Integrity – Gary D. Alexander, Secretary, PA Department of Public Welfare
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Program Integrity Initiative
July 2011 to October 2011
As-Is Gap Analysis To-Be
Enterprise Program Integrity – Gary D. Alexander, Secretary, PA Department of Public Welfare
Program Integrity Initiative
July 2011 to October 2011
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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
Enterprise Program Integrity – Gary D. Alexander, Secretary, PA Department of Public Welfare
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
Enterprise Program Integrity – Gary D. Alexander, Secretary, PA Department of Public Welfare
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
Enterprise Program Integrity – Gary D. Alexander, Secretary, PA Department of Public Welfare
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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
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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
Enterprise Program Integrity – Gary D. Alexander, Secretary, PA Department of Public Welfare
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
Enterprise Program Integrity – Gary D. Alexander, Secretary, PA Department of Public Welfare
Program Integrity Results
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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
Enterprise Program Integrity – Gary D. Alexander, Secretary, PA Department of Public Welfare
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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)
Enterprise Program Integrity – Gary D. Alexander, Secretary, PA Department of Public Welfare
Program Integrity Results
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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
Enterprise Program Integrity – Gary D. Alexander, Secretary, PA Department of Public Welfare
Program Integrity Results
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
Enterprise Program Integrity – Gary D. Alexander, Secretary, PA Department of Public Welfare
The Council of State Governments – Innovations AwardJuly 20, 2012 – Atlantic City, NJ
Gary D. AlexanderSecretary, PA Department of Public Welfare
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