State of Washington Awards Program Integrity Contract to Ingenix
Olympia, Wash., and Eden Prairie, Minn. (July
28, 2009) – The Washington State Department of Social and Health
Services (DSHS) has awarded a $19 million, five-year contract to fight
and prevent Medicaid fraud, waste and abuse to Ingenix, a leading
information, technology and consulting services company.
Washington’s initial investment in the contract is funded by a $5.9
million Medicaid Transformation Grant awarded by the federal Centers
for Medicare and Medicaid Services (CMS). The Washington DSHS grant
application to CMS outlined the goal of creating a second-generation
fraud and abuse detection system that would bring together “the tools,
resources, and comprehensive approach for detection and prevention of
fraud, waste and abuse…[that would establish] a national model for
Medicaid payment integrity.” Over the course of the new contract with
Ingenix, Washington expects to recover contract costs in the first year
of operations, with an increasing return-on investment ratio over the
life of the contract, expected to be no less than three-to-one.
The new contract builds on work Washington has undertaken with Ingenix
over the past eight years to achieve breakthrough financial results in
Medicaid Program Integrity, or the ability to eliminate fraud, waste
and abuse from Medicaid programs. During that time, the State has
realized more than $60 million in cost savings, most in actual dollars
recovered, not merely dollars identified as improperly expended. To
achieve this, Washington’s DSHS worked with Ingenix and other subject
matter experts to mine health care claims data. Using Ingenix
rules-based algorithms, peer group models, data analysis tools, and
provider self-review functionalities, DSHS was able to identify,
prevent, and/or recover inappropriate payments to health care providers.
The new contract with Ingenix will enhance the State’s Medicaid Program
Integrity efforts, mainly by helping DSHS focus more effectively on
preventing fraud, errors and abuse before they occur. The new contract
enables the DSHS partnership with Ingenix to evolve from a “provider
collection” program integrity model, in which fraud and abuse is mainly
identified retrospectively, to a prospective program integrity model
with emphasis on preventing errors, fraud, waste and abuse. To
facilitate the shift, DSHS selected Ingenix’s products, services and
tools; clinical and analytical expertise; project management and
consulting capacity; and subject matter expertise in areas such as
managed care, and fraud, waste, and abuse detection techniques.
“Washington has always considered itself on the forefront of efforts to
fight Medicaid fraud and abuse,” said Doug Porter, Assistant Secretary
for the Health and Recovery Services Administration in DSHS. “With the
current state of the economy, it becomes even more critical to ensure
that every dollar spent by Washington taxpayers goes to health care
services that people need.”
Said Tom McGraw, senior vice president of Ingenix Government Solutions,
“The State of Washington serves as a model for applying innovative
technology and analytics to protect the integrity of Medicaid payments.
Washington’s increased focus on prospectively eliminating errors,
fraud, waste and abuse from the system will help to further reduce
costs and ensure that Medicaid works better for everyone in the State.
We are grateful to serve as a trusted partner to the State as they work
to achieve the next level of program integrity.”
About Washington DSHS
Washington’s Department of Social and Health Services (DSHS) provides
medical and social services to over one million low-income residents –
paying $4 billion annually to more than 40,000 medical providers and
$1.6 billion annually to more than 80,000 social service providers.
Washington’s Medicaid Program Integrity efforts cover Medicaid and
social service payments for all of DSHS. Program Integrity Staff are
consolidated within the Health and Recovery Services Administration’s
(HRSA) Division of Systems and Monitoring (DSM). Program Integrity
efforts are led by the Payment Review Program (PRP) and the Office of
Payment Review and Audit (OPRA). The HRSA PRP is nationally recognized
for its progressive and innovative approach to the detection and
prevention of Medicaid fraud, waste and abuse through the use of
sophisticated data mining processes and analysis.
About Ingenix
Ingenix, a UnitedHealth Group company (NYSE: UNH), transforms
organizations and improves health care through information and
technology. Organizations rely on its innovative products, services and
consulting to improve the delivery and operations of their business.
More information about Ingenix can be obtained at www.ingenix.com.
Ingenix’s Government Services division is the nation’s leading business
intelligence and program integrity solutions provider for government
health and human services agencies. Ingenix believes that health
information technology is an essential component in efforts to reduce
costs and improve quality in Medicaid and Medicare systems. Ingenix
solutions help manage one of every three Medicaid dollars nationally,
and more than 25 percent of total Medicaid beneficiaries. We serve in
27 states, including six of the largest Medicaid programs by budget.
ABOUT CMS and MTG grants
The Centers for Medicare & Medicaid Services (CMS) is the US
federal agency which administers Medicare, Medicaid, and the State
Children's Health Insurance Program. Congress directed CMS to fund
Medicaid Transformation Grants (MTGs) for the purpose of encouraging
states to “adopt innovative methods to improve the effectiveness and
efficiency in providing Medicaid.” The implementation of MTGs provides
new opportunities for States to work with the Federal Government to
build on effective reforms to slow spending growth while providing
needed and quality healthcare coverage.
