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An Act To Require the Department of Health and Human Services To Report Annually on Investigations and Prosecutions of False Claims Made under the MaineCare, Temporary Assistance for Needy Families and Food Supplement Programs
Emergency preamble. Whereas, acts and resolves of the Legislature do not become effective until 90 days after adjournment unless enacted as emergencies; and
Whereas,  the discovery and investigation of program integrity issues made under the MaineCare, Temporary Assistance for Needy Families and food supplement programs are beneficial to the State and lawful participants in the MaineCare, Temporary Assistance for Needy Families and food supplement programs; and
Whereas,  decreasing the number of fraudulent claims made under the MaineCare, Temporary Assistance for Needy Families and food supplement programs is beneficial to the State and its citizens and should begin as soon as possible; and
Whereas,  in the judgment of the Legislature, these facts create an emergency within the meaning of the Constitution of Maine and require the following legislation as immediately necessary for the preservation of the public peace, health and safety; now, therefore,
Be it enacted by the People of the State of Maine as follows:
Sec. 1.  22 MRSA §§20 and 20-A  are enacted to read:
§ 20. Report of department’s efforts to investigate MaineCare program integrity
The department shall design a comprehensive and well-coordinated system to ensure that public funds are well managed and dispensed for the purposes for which they are appropriated and deliver the best value for the people that they serve.
The department shall report annually by February 15th to the joint standing committee of the Legislature having jurisdiction over health and human services matters and the joint standing committee of the Legislature having jurisdiction over financial affairs regarding MaineCare program integrity efforts of the department, including efforts to investigate and prosecute fraudulent incidents or practices. The report must contain the following information:
 
1.  MaineCare programs.     The following baseline information for the prior year for MaineCare programs:
 
A.  The total unduplicated number of households, children, persons with disabilities and seniors receiving assistance under each MaineCare program; and
 
B.  The total MaineCare program expenditure in general funds, federal allocations and any special revenue funds;
 
2.  Description of program integrity efforts of department.     A description of the department's efforts under this section, including any efforts made in cooperation with federal agency partners in investigating and prosecuting fraudulent claims and overpayments and provider, vendor and retailer fraud and overpayment, including:
 
A.  The number of staff investigating cases;
 
B.  The number of cases opened, investigated and disposed of;
 
C.  The sources of the cases opened;
 
D.  The dispositions of the cases closed;
 
E.  The number and amount of fraudulent overpayments recovered and fines or penalties actually imposed, expressed in absolute dollar values and as percentages of all funds spent in each program;
 
F.  The amount of recoveries of fraudulent claims reclaimed by the Federal Government;
 
G.  All costs associated with all activities related to discovering, investigating and prosecuting cases in which fraud was alleged, whether or not fraud was determined to exist, for each program, both in absolute dollar values and as percentages of each program;
 
H.  The average length of time to recover fraudulent overpayments and fines or penalties imposed from the time cases are opened until the time overpayments and fines or penalties are repaid in full;
 
I.  The amount of fraudulent overpayments determined as uncollectible;
 
J.  The amount of fraudulent overpayments recovered by type of offender;
 
K.  The amount of fraudulent overpayments recovered by a business unit within the department's audits and program integrity activities group;
 
L.  The number of MaineCare providers, retailers or vendors, by type, that are terminated from participation or otherwise sanctioned from participation in public programs as a result of program integrity activities;
 
M.  The amount of all recoveries of fraudulent overpayments received as a result of multistate litigation against pharmaceutical companies or other providers; and
 
N.  The dollar amount, by provider type, of any overpayment recoveries;
 
3.  Referrals to Attorney General.     The status of cases referred to the Attorney General's health care crimes or other unit or other law enforcement entities and the number and disposition of those cases and the amount of overpayments recovered, all detailed on a per case basis;
 
4.  Performance and activities of vendor, contractor or other program integrity unit used by the department.     If the department uses a vendor, contractor or other program integrity unit to assist in the identification and recovery of overpayments, a description of the performance and activities of the vendor, contractor or other program integrity unit used by the department. The report must include what the scope of the vendor's, contractor's or other program integrity unit's activity is, what payments have been made to the vendor, contractor or other program integrity unit, how many cases have been opened, how many overpayments have been recovered and any other benefits from the vendor's, contractor's or other program integrity unit’s involvement;
 
5.  Department's participation in federally mandated program integrity efforts.     A description of the department's participation in federally mandated program integrity efforts, including the federal Centers for Medicare and Medicaid Services Recovery Audit Program and Payment Error Rate Measurement program, and the impact of this participation on department resources and money recovered and the number of providers sanctioned and referrals made as a result of this participation;
 
6.  Results of federal audits.     The results of any federal audits of the department's program integrity activities, including weaknesses identified and best practices identified;
 
7.  Defects, deficiencies or weaknesses in department systems.     A description of any known defects, deficiencies or weaknesses in any systems managed or used by the department that resulted in the improper or inaccurate payment of claims or benefits, including but not limited to the Medicaid information system, provider enrollment system and eligibility determination system. The report must include an estimate of the financial impact of these issues and a timeline for remediation and a description of any known defects, deficiencies or weaknesses in any systems managed or used by the department that have been corrected and an estimate of the cost of and any savings from these corrections;
 
8.  Planned investments in technology.     A description of any investments in technology planned by the department to improve efforts to prevent improper payments; and
 
9.  Policy changes or improvements.     A description of any policy changes or improvements implemented by the department to improve the accurate payment of claims and benefits.
§ 20-A. Report of department’s efforts to investigate program integrity made under the Temporary Assistance for Needy Families and food supplement programs
The department shall design comprehensive and well-coordinated systems to ensure that public funds are well managed and dispensed for the purposes for which they are appropriated and deliver the best value for the people that they serve.
The department shall report annually by February 15th to the joint standing committee of the Legislature having jurisdiction over health and human services matters and the joint standing committee of the Legislature having jurisdiction over financial affairs regarding the program integrity efforts of the department in the Temporary Assistance for Needy Families program and the food supplement program under section 3104, including efforts to investigate and prosecute fraudulent incidents or practices. The report must contain the following information:
 
1.  Temporary Assistance for Needy Families and food supplement programs.     The following baseline information for the prior year for the Temporary Assistance for Needy Families and food supplement programs:
 
A.  The total unduplicated number of households, children, persons with disabilities and seniors receiving assistance under each program;
 
B.  The average monthly benefit for each program in general funds, federal allocations and any special revenue funds; and
 
C.  The total program expenditure in general funds, federal allocations and any special revenue funds for each program;
 
2.  Description of program integrity efforts of department.     A description of the department's efforts under this section, including any efforts made in cooperation with federal agency partners in investigating and prosecuting fraudulent claims in the Temporary Assistance for Needy Families and food supplement programs, misuse of public benefits instruments investigated pursuant to Title 17-A, section 905-C and vendor and retailer fraud, including:
 
A.  The number of staff investigating cases;
 
B.  The number of cases opened, investigated and disposed of;
 
C.  The sources of the cases opened;
 
D.  The dispositions of the cases closed;
 
E.  The number and amount of fraudulent overpayments recovered and fines or penalties actually imposed, expressed in absolute dollar values and as percentages of all funds spent in each program;
 
F.  The amount of recoveries of fraudulent claims reclaimed by the Federal Government;
 
G.  All costs associated with all activities related to discovering, investigating and prosecuting cases in which fraud was alleged, whether or not fraud was determined to exist, for each program, both in absolute dollar values and as percentages of each program;
 
H.  The average length of time to recover fraudulent overpayments and fines or penalties imposed from the time cases are opened until the time overpayments and fines or penalties are repaid in full;
 
I.  The amount of fraudulent overpayments determined as uncollectible; and
 
J.  The amount of fraudulent overpayments recovered by type of offender;
 
3.  Referrals to Attorney General.     The status of cases referred to the Attorney General's health care crimes or other unit or other law enforcement entities and the number and disposition of those cases and the amount of overpayments recovered, all detailed on a per case basis;
 
4.  Performance and activities of vendor, contractor or other program integrity unit used by the department.     If the department uses a vendor, contractor or other program integrity unit to assist in the identification and recovery of overpayments, a description of the performance and activities of the vendor, contractor or other program integrity unit used by the department. The report must include what the scope of the vendor's, contractor's or other program integrity unit's activity is, what payments have been made to the vendor, contractor or other program integrity unit, how many cases have been opened, how many overpayments have been recovered and any other benefits from the vendor's, contractor's or other program integrity unit's involvement;
 
5.  Department's participation in federally mandated program integrity efforts.     A description of the department's participation in federally mandated program integrity efforts, including the federal Centers for Medicare and Medicaid Services Recovery Audit Program and Payment Error Rate Measurement program, and the impact of this participation on department resources and money recovered and the number of providers sanctioned and referrals made as a result of this participation;
 
6.  Results of federal audits.     The results of any federal audits of the department's program integrity activities, including weaknesses identified and best practices identified;
 
7.  Defects, deficiencies or weaknesses in department systems.     A description of any known defects, deficiencies or weaknesses in any systems managed or used by the department that resulted in the improper or inaccurate payment of claims or benefits, including but not limited to the Medicaid information system, provider enrollment system and eligibility determination system. The report must include an estimate of the financial impact of these issues and a timeline for remediation and a description of any known defects, deficiencies or weaknesses in any systems managed or used by the department that have been corrected and an estimate of the cost of and any savings from these corrections;
 
8.  Planned investments in technology.     A description of any investments in technology planned by the department to improve efforts to prevent improper payments; and
 
9.  Policy changes or improvements.     A description of any policy changes or improvements implemented by the department to improve the accurate payment of claims and benefits.
Emergency clause.  In view of the emergency cited in the preamble, this legislation takes effect when approved.
 
SUMMARY
This bill requires the Department of Health and Human Services to report annually by February 15th to the joint standing committee of the Legislature having jurisdiction over health and human services matters and the joint standing committee of the Legislature having jurisdiction over financial affairs regarding actions taken by the department to investigate program integrity under the MaineCare, Temporary Assistance for Needy Families and food supplement programs, including the amount recovered, the cost of those investigations and prosecutions, the number of personnel working on the investigations, the status of cases referred to the Attorney General's office, a description of the performance and activities of a vendor, contractor or other program integrity unit used by the department to help recover overpayments, a description of the department's participation in federally mandated program integrity efforts, the results of federal audits, a description of defects, deficiencies or weaknesses in department systems, a description of planned investments in technology and a description of policy changes or improvements implemented.