Ohio Senate Medicaid Committee - 3-24-2026 - Joint Meeting of Medicaid Committees

I pledge allegiance to the flag of the United States of America and to the republic for which it stands, one nation under God, indivisible, with liberty and justice for all.

Senator Romanchuk?

Senator Huffman?

Senator Liston?

Senator Ingram?

Checked in.

Present.

Present.

Here.

Here.

Here.

Aye.

Here.

Representative Mullins.

Representative Olslinger.

Representative Romer.

Representative Somani.

Here.

thank you chair gross vice chair Roman Chuck recommender Linson members of the House and Senate Medicaid committees my name is Scott Partika I'm the current director of the Ohio Department of Medicaid thank you for the invitation today to appear before you to discuss fraud waste and abuse within the Medicaid program you know last month when we hear we talked through a number things that I shared a little bit around my focus coming into the role One thing in particular I talked about was a strong commitment to maintain the highest standard of fiscal responsibility so that the program remains sustainable and affordable well into the future. A lot of the work I have today and a lot of the work since I started, a lot of it kicked off around that specific initiative, And a lot of that has evolved into a larger program integrity in identifying fraud, waste, and abuse as a natural result of doing program reviews. The work that we are doing, closely rooted, working with our provider, different community partners, as well as, of course, the legislature, but also the state auditor and attorney general. Equally important, we're focused on ensuring that program integrity is not just a priority of the organization, but something that becomes a core expectation that shapes every action we've taken. And we have been working to build that into our day-to-day function at the department, especially over the last couple of months, so that not only reviews that we're doing now have an impact, but into the future, there is an expectation and there's a system in place to root out issues before new policy or new programs are implemented. First, I do want to recognize the great partnership that we have with one of the best legal and fraud fighting units in the country in the attorney general's office. Certainly will allow him to speak more around their role and their function, but it is something that is critical to the success of our efforts to combat fraud, as well as the role of the state attorney in prosecuting various cases over the year that he has taken an interest in in particular, whether it's pharmacy benefit managers or opioid distributors. that impact of those cases have a downstream impact to the larger what I'll call program integrity or cost efficiency and management of the program that really have a critical role in our long-term success. So all of the work on that side as well does have a downstream impact outside of the day-to-day fraud fighting. In addition to that, and along that same lines, the Auditor State's Office does an excellent job, whether it's individual provider audits or larger performance or state audits of the Medicaid program, where having that opportunity for them to come in, identify, triage, and offer navigation on different ways that we could go about perhaps solving the problem or perhaps making improvements is something of value to have a third-party set of eyes coming in, while oftentimes identifying other states where maybe there's a best practice that we could refer to and use and have seen a great deal of success coming out of those, especially recently. I talked a little bit about electronic visit verification last time, but the implementation of that becoming a requirement directly came out of an auditor of state audit as the department was in process of having a new vendor for that role. And as part of that, we made it a condition of payment approval to add the requirement that all of the services in the home health space have that electronic visit verification. We are, in particular on that note, we are through the final phase of implementing the new system and that requirement, making dramatic improvements in the amount of folks who have that particular function done before payment and are continuing to look at ways to improve that function moving forward. So additional requirements or additional services that might be appropriate. Now that we through GoLive we beginning to turn and look that direction as well And in addition to that the auditor also identified concurrent enrollment as a risk to the Medicaid program previously We have been working in the federal government back in November, started sharing a master file, for lack of a better term, with states on where concurrent enrollment is happening or potentially happening, right, based on the information they have. And we were able to use that to triage down and say, where's a risk here in Ohio where maybe someone has not been removed from the rolls? And we're able to identify a number of individuals, about 6,000, that we did not have verifiable data or they did not have medical claims history, but they were on our rolls. So we removed them from managed care and put them on fee-for-service to monitor while they received the notice to provide the additional information. so those in failure to do so will result in them being removed from the Medicaid program, but that is having immediate cost savings as a result of that simple data sharing with us and the federal government, and us taking a little bit of time to dive in, look across our system, and see the impact of that data and make some decisions that are going to save us a significant amount of money here, especially in the short term. And then the provision of the big, beautiful bill that will require the federal system to be built to monitor that on a regular basis. Certainly, I think go live in 2028 is the expectation for that. In the meantime, I think the data sharing partnership is going to be a helpful bridge until that is built. So with that said, I've offered up in my written testimony. I will largely go through it, but I want to leave some time for questions at the end as well so I may skip through things. I provided some context around the definitions of fraud, waste, and abuse in Medicaid, which sometimes could be a tricky one to crack in terms of are we talking about fraud, are we talking about waste, and are we talking about abuse. We have adopted the culture and approach of when there's an identified problem, if it's fraud, waste, or abuse, we not only look at it from is it fraud from a law enforcement ends and, of course, all the steps that need to be taking place from that perspective, but really it's an unnecessary cost of the program. how can we potentially address it through other means in a larger systemic way? And that has been our approach. But the differences are subtle, but of course important as we think about how to remedy the particular problem. So if you have a particular area of concern, I think bringing it to us, we will take a broad approach of how do we identify where there might be unintended issues or unintended loopholes that were created that need close. so with that being said just a little bit of the basics of the different things we do engage the public and stakeholders and providers and other folks of course Medicaid fraud hotline housed over at the Attorney General office is one front door where claims can can come to the larger team for review is also a consumer facing hotline as well for folks to report a you know potential other providers in their space that may be committing violations in addition to that in our role I did want to mention because we do interact with them the HHS inspector general is another individual who receives tips that come in through various mechanisms as well as of course even within CMS whether they're finding things internally or receiving things directly to them there's good coordination on being able to transfer those to the appropriate folks With that being said a little bit around how some of the fraud allegations are investigated at the department in particular and I will skip over parts of the Attorney General role in this in particular in the interest of time. But first, here in Ohio, we've established an internal fraud referral clearinghouse, which is made up of various subject matter experts that as these claims come they're able to be quickly vetted and determined for for next steps this includes ODM staff our managed care partners partner agencies in the various other entities that submit referrals to FRC last year we had 748 referrals come through this front door the Attorney General of course receives other referrals through the other means but this is one warehouse that we used to look across the board at the various trends we might be seeing coming in the front door from Medicaid's perspective and then as I mentioned the the role of the Attorney General to review cases as they are coming in I will let them speak on that further then our Bureau of program integrity provider and audit compliance review unit or passer as endearingly referred to at the department they complete an analysis of all Medicaid provider types to determine whose providers may have increased from prior year in an unreasonable way and do audit and review and oftentimes provide technical assistance if needed to those who may have been billing. Then we have BPI's managed care audit teams. This is a group that works with managed care plans to identify fraud, waste, and abuse through various providers that enter their space or through their function then the ODM surveillance and utilization review section which conducts a large-scale data analytics to identify providers group of some providers potential billing schemes really what are we able to glean from the data that we are seeing that should be identified and sent to the fraud team for review and potential investigation and discipline Another factor I wanted to mention, and this is the Ohio Medicaid enterprise system. And this is, over the last few years, the build of the data warehouse, where all the data integrates with one another. And the value in having that all in one place and nearly in real time, we have certainly benefited from recently. as we've begun looking at some of these issues, to have claims data that is at our fingertips in most recent months has certainly been helpful as we've reviewed some of these potentially, these different areas of potential risk and not having to go back and piece together data. In addition to that, I talked about the role of the managed care plans. Each of them are required to have a special investigations unit that works closely with our team, the Attorney General's team, on identifying potential fraudulent providers. And I'll take this as a moment to say as well, in addition to that work of the SIU, the function of the managed care plan and their position within the larger health care system does provide additional oversight that I can't quite capture in one specific activity, but monitoring trends in their billing and looking for outliers and other functions does provide a level of oversight of the program as a whole. In addition to that, a few details around dedicated Fraud referral meetings that the department has where a lot of these claims are brought forward with a large group of folks to share background experience and potentially identify if there are other areas that need to be investigated, but then also whether or not claims should be accepted or rejected. One of the challenges, of course, is when claims come in, determining the credibility of the claim and the risk of the claim and using our resources to target the most high risk or situations. So this front-end review is not supposed to serve as a bottleneck for decisions getting to that step, but as a good filter to make sure the limited resources we have in this space are being deployed and focused appropriately. With that said, I think I'm mentioning here in the auditor of states access to the department's data. in addition to the auditor having access, the Attorney General as well, so they are able to go in, and as they are identifying different trends in their independent role from us, they are able to identify areas of investigation, and I think that is something of immense value, especially as we look long-term and moving forward. So I touched on this a little bit, but as we've done program reviews and thought about this holistically long-term, we view there's a few different areas where we have fraud, waste, and abuse capacity as a department. It's how do you go upstream, right? How do you avoid fraud from ever entering your system? How are you going midstream, where we are within the act of providing the service or submitting the claim, we are doing functions that are catching improper payments in the middle, and then downstream where we are after the fact potentially recouping dollars or only fold back. So I provided a little bit of background here, in particular on the upstream, the build out of the provider network module and the enrollment process so that we have a record of all of the providers within our systems and who may be contracting with managed care plans. A next phase of that, not included here, but as I mentioned with the managed care plans, They do have the ability to manage their network for folks who are in-network eligible for payment where there is an additional review that they can apply before folks are entering their network. Midstream, I talked already about electronic visit verification, but that is a good example of something that is not traditional fraud, waste, and abuse, but is something that is a valuable tool to plug in there during a claim submission to capture important data sets to make sure we are identifying any potential irregularities. Prior authorization and utilization management. This one is a widely used tool. I'm sure many of you have heard lots of different examples of prior authorizations, both being used well, and at times I'm sure you've heard a lot of the grievances around the use of prior authorization and the administrative challenges sometimes it faces on providers. I think the value of a prior authorization should always be, and our mentality is that it should always be focused on ensuring the right type of care is being provided, but we should be looking at ways to reduce the administrative burden when doing so and ensuring that doctors have as much time as possible with patients, but also making sure we have a check in place to ensure that the service was clinically necessary. So it an area that the plans are regularly reviewing our teams are regularly reviewing and right now we are currently doing several reviews around prior authorizations in the behavioral health space which has not been the case since managed care since behavioral health services were carved in and integrated into managed care we have not had in the community behavioral health space any prior authorizations. I think in effort to look at potential trends we are seeing in that space, prior authorizations will be one of several tools we think that we can use to address some of the irregular providers. But I think our mentality has been all along to do it in a way that is administratively responsible, and ultimately we do not want to limit someone's ability to offer a service or open a clinic, especially in a rural area, with an overly burdensome approach. So we are having very intensive discussions with both the plans and the providers in that area, and we'll be moving forward with that being a new tool used in that particular space. Lastly, third-party liability protections. This is, by law, the Medicaid program is the payer of last resort. So that is our responsibility to ensure that the legally obligated third-party sources to pay a claim before Medicaid pay. And ODM is working to ensure the law is complied with, focusing on cost avoidance, So ensuring commercial or public health insurance carriers pay for the service rather than Medicaid. So that would be commercial payers. That could be Medicare or commercial exchange, depending on the case. And that payment recovery is legally obtained. Cost report reviews is another area. At the end of each fiscal year ODM reviews the cost reports that are submitted by long-term care facilities and ICFs to ensure that the reports in the directed care services accurately reflect the cost. So in addition, we contract with Meyer Staffer, who does these reviews on our behalf, where they review a subset of nursing facilities and ICFs each year to go in and review those books and do an audit for their performance. The minimum data set is the tool that is used to conduct the assessment. And again, like I said, there's about 100 facilities that are reviewed each fall and spring. and then if the score assigned to the facility upon that does not match the audits assessment then the facility is adjusted down upward or downward depending on for payment for future years downstream as well I talked to already in a couple spaces around using data to do some data analytics work on top of the work we are already doing in-house and working with our vendors to pull and monitor for different trends we see in this space we actually are right now recently contracting with LexisNexis to come in alongside of us, JFS and DCY, to do a program assessment of potential risk among providers and other folks that we think, as I've mentioned here a few times, we've been doing a large program review. And I think the question is, how do you make it lasting? One of them, I think definitely is what type of risk assessment are you putting on, especially as we think about how are we identifying providers? using our resources to go in and do investigations appropriately part of that is what is the structure what are the indicators that we need to look what are the billing trends potential ownership structures or different things we need to identify so that we could go in you know with a scalpel and and kind of carve out those areas without impacting the the the other providers and in the process and that is a trend across the country as well something CMS has also been talking about and pushing As you look at fraud waste and abuse how can you risk stratify your issues so that you address them most efficiently without creating an exorbitant amount of additional bureaucracy between the doctors, the practitioners, the community behavioral health providers, and their patients. It's an incredibly difficult balance to strike, and we recognize that, but we are recognizing the importance of program integrity and something we're committed to do moving forward. So I talked a little bit already in particular, some recent work we noted on here. In addition to 60 program reviews we were doing, enrollment in our eligibility system is another area, not traditional fraud, waste, and abuse always, but ensuring we are in compliance with all federal guidance on how to implement different rules. And so changes we made over the last year, as I talked about last meeting, has resulted in our caseloads dipping below the projections as a result of those changes. And we continue to work with the federal government and ensure we are in full guidance with both their interpretation of the guidance, expectations, and then, of course, moving forward on things like work requirements and ensuring, as I talked about last time, that we are meeting their expectations there. In closing, I'd like to ensure Ohioans receive the health care that they deserve, that they need, and that the right care is delivered in the right place at the right time for individuals who need it. I respect the fact and appreciate that the dollars allocated by this General Assembly are going to be properly spent and in accordance with the law. Chair Gross, Vice Chair Romanchuk, Ranking Member Limson, and members of the House and Senate Medicaid Committee, thank you for the opportunity to review our efforts to combat fraud, waste, and abuse in the Ohio Medicaid program and look forward to the continued dialogue moving forward. I'm happy to answer any questions you may have today, and I'm always happy to answer your phone calls, your emails, your questions. If you are identifying something, you have something of concern, please reach out to us, reach out to our legislative liaison. Let us know so we could be vetting it and helping advise everyone moving forward.

Representative Romer. Thank you so much for coming in. Chair Gross, probably a year ago or more, brought some folks in to talk about the Ohio Medicaid program, compare it to some things going on in other states. And one of the states that was identified as possibly the best in the entire country is Indiana. And I know Indiana uses a lot of data to make sure, one, that people are eligible, they continue to be eligible, that they're citizens, all of those types of things. I just had a meeting about, I don't know, a week, maybe two weeks ago with some folks that practice both in Indiana and Ohio. They raved about Indiana. Do we, as an example, you just in your testimony mentioned using LexisNexis, but from a more provider perspective. Have we looked at using things like LexisNexis data to determine if people really are Medicaid eligible, and do we need to continue to audit that on a yearly, semi-annual basis?

Well, excellent. Thank you so much. I appreciate it.

Thank you, Chair. Thank you for coming today. Years ago, I was on the now, I think it's defunct, ambulance board here in the state of Ohio. And we had a lot of fraud that came through ambulance companies. And one of the ways we were able to limit that fraud was making sure in our inspection process that if it was a legitimate business, it would have legitimate business expenses they would have to prove in the licensing process. One of those was having a certificate of liability insurance, a valid certificate of liability insurance. And I'm not familiar enough with the processes of Medicaid as far as the inspection goes, but if we were able to, as the legislature, as the legislature, that's okay, go ahead. If we were able to, as the legislature, to provide the Department of Medicaid with some framework to make sure that you have the ability to test providers that they would have, you know, a normal legitimate business would have these expenses and they would be very verifiable. Somebody who's conducting fraud and has, you know, 10 businesses under the same roof, let's say, they would not want to buy 10 different liability insurance policies. And if they have that valid, then you have the insurance companies and you have a whole other network of legitimacy vetting people before they get to Medicaid. Do you know anything of that?

Appreciate that.

Absolutely.

And I would say to that was, as a property and casualty insurance person, as opposed to a health insurance person, it was a way to be able to catch somebody or to verify very easily. And you have other sources that are verifying that information. But the problem that we had was nobody else on the board knew what a certificate of insurance was like for your auto insurance for an ambulance. So it was very easy to slip through the cracks if the staff or if somebody was not familiar with that sort of thing. So I would encourage, as you guys are looking at ways to make sure that people are doing what they're supposed to be doing, that we utilize people from other fields of the business world to verify that somebody is a legitimate business. So thank you.

Senator Huffman. Thank you. I've got a question about presumptive eligibility. You know, I saw the first study I saw was in 2019 that the Ohio Medicaid had about a 40% fail rate of presumptive eligibility. And after a lot of prodding by the General Assembly, the recent report that came out, which basically the General Assembly kind of mandated the department to do, is you're only at 20%. I don't know what business would accept 20% failure rate in presumptive eligibility, But what can we do about it and how can it continue to be so high because the federal government has given us a mandate to get that number down before there's some penalties that kick in?

Chair Gross Senator Huffman my name is Jeff Corzine and I the chief of program integrity for the Medicaid program and reporting on QE falls under my responsibility I getting used to this process and the new reports that you asked for A couple of things that I've seen in the first set of reports is that the period of time that you're asking us to report on is not long enough in order to show the tail that's necessary for someone to apply. So when someone comes into a doctor's office or an FQHC or a hospital, they're going to get their services. They're going to go through this process. But then they're required within a certain period of time to then complete their application at the JFS office. Sometimes they do it. Sometimes they don't. that generally falls out of the realm of impact that that QE entity can make and having that person complete the circle and apply for coverage. And then sometimes it just takes a long time for someone to apply and provide all the necessary documents to complete the application. And so for the reporting period, we're sometimes catching that QE off guard in that the applications may still be in process. So if you do 10 applications and four of them are still in process, you have a 60% completion rate. So it's easy to have the results skew. I think we would both collectively get a more true picture if maybe we looked at a six-month window so that we could make sure that the individual completes their process, that the county completes its process. Because the other piece here is the person goes into the county and completes an application and needs additional information. The county can't complete the application until the consumer does that. So there are a lot of factors that go into this that I think just add to that error rate.

complete an application within 30 days of the event. Is that the member or? The consumer should be submitting a full application at the county within 30 days.

Thank you, Senator.

Through the chair, to the representative. that specifically I think you mentioned a good point there around recruitment of fraud that has happened and that is something that is a function of various entities that could fall on to the auditor at times the Attorney General of course in different spaces but also the department and the department with the managed care plans on doing post payment reviews at times and it certainly a function And if there were identified issues in the past as we were going through this review right now we do have the ability to do those post-payment reviews as one tool. Moving forward, the timeline in terms of implementing prior authorizations, I believe will be pretty quick. We are meeting three times a week right now, two times a week with providers and plans to talk through how do we efficiently do this and how do we do it. And we do it quickly so that, one, the practice could become implemented sooner rather than later, but at the same time looking at systematically are there potential rules or other things that we need to address. I think one of the things we've found sometimes is if you push down on the balloon on one particular area and don't account for other ones, that you could potentially cost shift some of your problems or shift some of your problems. So the large review we've been doing, like I said, that has been moving along pretty quickly, especially recently since the federal restrictions were lifted after the HCBS money through the ARPA grants that was used had expired. and we've been released in mid-February. So I would expect that coming shortly.

Okay.

Through the chair, to the representative. I do not have my team that works on that on the day-to-day here with me to pinch hit. So I apologize. I'm not quite fully prepared to speak to those. But I will opine slightly on one particular area as we looked at the partnership during this administration that has been formed with the accountable care organizations that are run by children's hospitals that have grown since we have taken office in the relationship that they have with the plans. And as part of that, we had worked on aligning the quality work so that everyone's at the table together, and it's not just a financial relationship, but there are shared efforts. So whether that be ensuring protocols and access to asthma inhalers or its follow-up after an ED visit for a behavioral health crisis, we've narrowed the focus of the areas that those arrangements would be working on from a quality improvement standpoint, and we're starting to see real measurable results that candidly differ from past efforts kind of broadly across the board. and I think our team's observation has been through that, and I won't speak for the plans or the ACOs, but our observation has been getting the leaders from those organizations just simply at the table and focused on tackling those big issues We able to see real results because we able to turn that quickly into practice We don spend too long studying and coming up and thinking and then passing it on to someone else in the organization, but we quickly have the people who can make decisions at the table, identify best practice, and then implement. so we are seeing improvements in a lot of those areas in a very big way, whether it's primary care visits or follow-up after ED utilization or access to sickle cell treatment that I think is encouraging. As far as more broadly than that, I would certainly have to prepare time to come back and follow up with you.

Nope.

Through the chair to the representative, that varies across payer types.

So in the Medicaid program, if we do have a prior authorization on a particular service, that is a decision that ultimately is authorized by the managed care plan for coverage through a review with the managed care plan and in that case the patient's doctor to review for medical necessity and cost effectiveness. I will say it is a very, very difficult area to monitor from where we sit and broadly. I think many folks share that same challenge. And so as we are looking at using those tools moving forward, we are trying to be cognizant of the fact that there are oftentimes very difficult situations that do require a thorough review. And the department does have an appeal process to appeal to the department as those arise that we monitor and engage the plans on to be sure they are done to proper fidelity.

Through the chair to the representative, that most often is a review of the case notes from the physician and the care team to ensure certain clinical criteria are included. In those case notes, to authorize that is often the first step. Of course, there's often consults between the managed care entity and the physician or other members of the care team to discuss if there's a disagreement. But I think the first layer of that is ensuring there's clinical documentation of need in place before that review is done. Thank you.

To the chair, as we look at that relationship broadly, as much as possible we can have cross-sharing of information. And I think that was one of the causes. I mentioned the fraud clearinghouse that we developed so that everyone kind of had access to that view of what was being identified, at least from our end, which helps both internally at the department but as we work with our partners at the AOS and at the AG. I will turn to my BPI chief to see if there is anything commenting around kind of that day-to-day as that works, especially maybe as the auditors are doing those reviews and how those are handled once they come back to us. We always follow up and ensure that the assessment aligns with, of course, the law before we issue the adjudication. But, I don't know. Jeff? you'd like to share?

Absolutely.

Thank you. I appreciate your thorough explanation of that. So just to follow up then, are there any specifics? I'm assuming these people are wearing multiple hats. Or are they specifically identified to be employees to identify fraud within our ginormous Medicaid system? Or are they wearing multiple hats? And then secondly, is there a reporting system where the people of Ohio can access what reports have been put out there, what reports have been acted upon, not just when the AG and the auditor do, but from Medicaid? Is there any type of reporting system to the legislature, the Senate, and the House so that we are aware of the level of the issue, whether it be fraud, waste, or abuse? I know that was a multiple question.

Thank you very much for that. I would like, I don't want to, in the military we call it death by PowerPoint, but I don't want to unfairly burden some of the 85 FTEs, But that information to brag on what they're doing, what they're accessing, what they're seeing, I think would be very helpful for us to know what you are doing. That way, when the people of Ohio come and say, what is Ohio doing with all the news, that we can say, here's what we were doing. Director, I just also wanted to ask you as well, how many FTEs total in Medicaid do you have, understanding that I'm going to take that 85, and I'm going to say the percentage of that in your current FTEs is finding fraud. I would like to see those reports. So how many active FTEs are we employing right now? I know that not all the positions are filled. We spoke about that.

No, you can do it. I know it was about 800 of FTEs, not all filled.

So then 80. How many? I heard of 700.

So one out of every seven is with fraud detection. I would like to see some results there.

Through the chair to the representative.

Do you have any of that data? So through the chair to the representative, I'm glad to follow up with the specific data around the cost of these activities. And I would say, though, I think the challenging part at times as we look at combating fraud, waste, and abuses, the specific activities that are dedicated towards it, towards, you know, for every credible fraud allegation allegation and fraud indictment that we have, the measure of what did that also stop because of having those tools in place to catch folks is sometimes a challenge to measure. We were actually just talking about that as a team the other day when we were wrapping up a meeting around how do we measure fraud, waste, and abuse efforts. So to the chair's question as well, I think it's a very good one of how are we measuring it, and I received a similar one from the vice chair during my testimony over there for confirmation. And it's something that I think we have said, well, part of this challenge is identifying how well are we identifying where the risk is. And that is a deliverable that I think we owe back to folks of where are the risks and what are the key indicators we look for. So as part of our work going forward, that is something we are doing to establish. And so I apologize to not directly answer the question. Again, glad to follow up with the data on the expenses that are dedicated in that space I will say that to make it even more complicated our efforts not just banning the FTEs on Jeff team but I think that mentality and something that we are addressing as a large agency, whether folks are in policy or they're in legal or they're on the IT side, is certainly somewhere where we are starting to have more and more folks, I think, engaging in these conversations. It's not their direct day-to-day activity, but it is becoming more of a side-of-the-desk function, or maybe not as much side-of-the-desk anymore, but more center-of-the-desk function. But we could absolutely at least provide the follow-up on the expenses tied to that work. Follow-up?

Through the chair to the representative, I think the first and foremost priority is these efforts are not focused and should not be focused on reducing needed health care for individuals in any way. I think the efforts are really focused on identifying, especially on the waste and abuse, where it is harder at times to identify what is waste and what is abuse. Our efforts should be focusing on making sure that that care is appropriate. and is being delivered as much on the front end as we can, so there is not as much of a need on the back end. Like in law enforcement, the perfect result would be we would put all of our fraud fighting team out of business because we've created a system that stops it on the front end that we recognize will not happen in the next year, probably will not happen in the next three or four years, but that is our focus. But alongside of that, to your point, I do think we have to be responsible in making sure any of these changes we're making are not making it impossible for somebody to either practice business or provide services when it's needed. And that is a difficult balance that we have been wrestling with as each and every issue has popped up for us to review and glad to share more of

To the chair, it's a great question. We do have some rules that are now filed and that will be moving through the JCAR process and we will likely be having more. I think that is one particular area where, as you guys are hearing feedback, we don't always hear or you have concerns. We would certainly ask you to engage us in that process. We are certainly open to, again, we are moving very quickly with some of these reviews that maybe not as long of a runway as we had in the past as we've looked at new rules. And part of that we'll be using the JCAR process to identify potential gaps. we recognize those might exist. So that area is one in particular. And I can't say that there will not be other requests that might require ORC changes, whether it is a function within Medicaid or a function of a licensing entity role and responsibility, there certainly could be opportunities for us to use to address where I think having this body who is focused on these issues by and large aware and able to help advise, we absolutely welcome it. I've got several notes even just from today's questions of different areas we can go back and use and kind of assess what are we doing, what are we not doing. So that would be our commitment moving forward.

Thank you, Chairwoman Gross, Vice Chair Romanchuk, members of the House and Senate Medicaid committees. I appreciate the opportunity to testify today about our daily fight to combat fraud, waste and abuse in the Medicaid system, a fight that I have in my 16th year, having previously been on the front lines as auditor of state. Here with me today is Health Care Fraud Section Chief Benjamin Karish. He is an expert on our investigations into Medicaid fraud, and should I encounter a question from any of you that I am unable to answer, I will turn to him and look for some help. A little background, Ohio's Medicaid Fraud Control Unit, the Impropiciously Acronymed MFUKU, exists within our office under the health care fraud section. The MFUKU aggressively investigates Medicaid provider fraud as distinct from recipient fraud and is among the best in the nation at rooting that fraud out. Any entity that provides Medicaid services is subject to the investigative authority of our office. Some of the examples of the providers under our investigative scope are hospitals, nursing facilities, pharmacies, doctors, dentists, home health providers, medical equipment providers, and behavioral health counselors. For the past 10 years in a row, Ohio's Mafuku was the first or second in the nation for securing fraud indictments and convictions. And in 2022, my team won the Health and Human Services Office of the Inspector General Award for Excellence in Fighting Fraud, Waste, and Abuse. Since I took office in 2019, our office has convicted 1,048 individuals for Medicaid fraud and recovered over $228 million for the state of Ohio. Inspector General members at the federal level have told us that Ohio is the model unit for catching Medicaid fraud. We routinely host trainings to show other states how to investigate and prosecute fraud because we do it well. We are catching fraudsters, and we are convicting them. In addition to the aggressive work of our Ohio Mofuku the strength of our prosecutions comes from our commitment to innovation The Health and Human Services Office of Inspector General granted our office a data mining waiver in October of last year What this means is that for the first time, Ohio is not merely responding to reports of Medicaid fraud or suspected fraud, But we are actively using data mining tools within the Medicaid database to look for irregular patterns. With the waiver in hand, we began implementing AI tools to help generate leads for our fraud investigators and analysts to act more quickly and efficiently. Artificial intelligence assists us in spotting irregular billing patterns for our investigators to manually vet. I want to make it clear that this only generates leads. We're using AI to generate leads for human investigators. We still have to put a case together. We still have to have proof beyond a reasonable doubt if there's a criminal case. But AI is proving to be a force multiplier for us. In the month of March, we announced our first indictments using data mining. We brought charges against 10 individuals who have stolen more than $578,000. In addition to the help from AI, our investigators are ramping up surveillance capabilities with more field deployable cameras. We have tools and technology necessary to catch fraud in the field. and use an array of undercover equipment to conduct surveillance. Let me explain why that's important, because we frequently hear everybody talking about billings and paper cases, and that's surely important. But here's a case of a home health aide who would pull up to a recipient's residence in her car, log in through the electronic visit verification system, and then leave. She'd come back six or eight hours later, claiming that she had been there for the entire time. I'm not making this up. A surveillance camera outside the recipient's residence over the course of a month also revealed the provider didn't appear much on video for several days at a time. She was only at the house for 15 minutes, maybe, for each claim. GPS data showed that she was signing in from her home, showing up just to do a wellness check on the recipient, and then went home. And that was it for the day. The dedicated and thorough surveillance done in that case allowed us to secure a conviction. Many of our investigations require this kind of field work, but our agents are also resourceful when it comes to doing the data and records, using the same techniques that all other law enforcement uses. Here's a few illustrations. Behavioral health. We secured a conviction against a woman who submitted false claims for day habilitation and camp services for children with autism. Listen to this. Parents reported that they were not getting the service that this woman claimed to provide. The parents were saying she didn't do the work. Email records proved to our investigator that she claimed services billed services when the children were not present including on weekends and holidays And some of the claims she claimed to provide services up until the middle of the night Behavioral health is another area. Here's a fraud case that happened more recently. Our investigators scoured email records and ATM and bank footage to secure a conviction for a woman using fake identities to operate phony behavioral health counseling agencies One of her fake identities, a real person that she stole their identity, was flagged for high billing. The victim of her identity theft told our investigators she never even worked for the company. Nobody ever received any services, and the woman in that case tried to get away with her crimes by fleeing the estate. Well, we tracked her down. Substance abuse. we secured a conviction for a man submitting false claims for substance abuse treatment services. Here's what we found in that case. Investigators compared his notes and discovered lengthy patterns of copying and pasting the case notes. Dr. Huffman, you know how individualized those case notes and progress notes are for each individual,

Some people did receive services there, but far fewer than what he was billing for. And we also discovered that he claimed to render services when he was actually proven to be out of state. It wasn't even in Ohio. At one point, the investigators tracked down casino footage to prove he was gambling when he was supposedly providing substance abuse treatment. He was using funds he had stolen. Durable medical equipment. We could secure a conviction against a doctor billing for far more medical equipment than he was providing. He liked to bill for custom back braces. Claimed to order over 5,000 of them. There were actually 500, a tenth of what he billed for. Most of our fraud convictions come from two provider types, home health and behavioral health. These two provider types are considered higher risk for fraud for multiple reasons. First, there's a low barrier for entry into these kinds of jobs. Secondly, providers operate in an unsupervised environment frequently at the recipient's home. the patients tend to be more vulnerable or not noticing or challenging fraudulent building, such as the elderly or even individuals with cognitive impairments. These challenges were unfortunately exacerbated by Medicaid's expansion under the Affordable Care Act. Ohio dramatically, as you know, expanded eligibility in 2014 under the ACA, and more than 700,000 Ohioans were added to the Medicaid rules. While the number of Medicaid recipients has hovered around 3 million for the last 10 years, the number of claims increased by almost 12 million. As Medicaid expands to cover more services, that corresponds with a dramatic increase in providers. So in 2012, we had about 75,000 Medicaid providers in Ohio. Now there more than 200 This is a combination of growth factors More people more services more providers obviously presents some additional challenges on the fraud investigations Despite these challenges, Ohio leads nationally when it comes to combating health care fraud. With all that laid out before you, I can confidently say that we do have scrutiny and accountability of Medicaid here in Ohio. Like any system, though, I can also confidently say we can do better and we should do better. And I'd like to offer this committee a few ideas on tools that you could give us that would increase our effectiveness. First, Medicaid fraud shouldn't be treated as less serious than any other theft. Do the members of the committee realize that it's capped at an F3? It can't be any higher than that. But if you have a serious theft, millions of dollars, it can be a felony of the first degree. We should make the statutory penalties for Medicaid fraud match every other kind of theft. Personally, I would like to see it even elevated because they're abusing public trust here. It's not just I stole from Joe. It's I stole from the public that trusted me to provide these services. But in any event, it should not be capped at a third-degree felony. Secondly, the GPS requirement needs to be required again in the electronic visit verification system. Home health professionals use this system to log in and out for their various times of providing service. Until about a year ago, it was required. Now it's optional. And you heard some stories about how that happens. Chairman Gross, Vice Chairman Roman Schuch, I was auditor of state, and my audits led to that GPS requirement. We asked for that technology to be adopted. I do not know for the life of me why it went away, but I respectfully ask you to put it in statute where no bureaucrat, no vendor can object to legitimate monitoring of whether they actually are on the site of where they're providing the services. Thirdly, more services should provide, should require prior authorization. You heard the director talk about this a little bit. we shouldn't have to chase down our dollars after they're out the door. And finally, please grant Ohio Mifuku subpoena authority. Now, the easy thing to do would be just to give us civil subpoena authority. I already have that in a variety of places in my office, and it would be helpful to have it. We can provide some, and the other statutes that give us a subpoena authority, put some guardrails around it. They keep the, you know, I'm not allowed to announce, for example, the findings of those subpoenas or that an investigation is underway unless and until it results in a civil or criminal complaint. Fine with that. but give us the subpoena authority to go after these records. And candidly, even better would be grand jury subpoenas. Now, don't get me wrong, I am not trying to take away from our county prosecutors their right to bring these Medicaid fraud cases in their counties. What I'm talking about is access to the grand jury subpoena process where we can compel through a criminal grand jury subpoena productions of things that we might not be able to reach through a civil subpoena. we could still preserve that right now the way this works is if there's a Medicaid criminal case it goes first to the county prosecutor and they've got a period of time to say yeah I'll do it or to turn it and say no I don't have time and then my office has a springing authority to prosecute it that's a great system, no need to turn it upside down. But here's the truth of the matter. Our county prosecutors are drowning in drug cases and sex cases and assault and murder. They do not have the time to conduct these technical and admittedly kind of arcane investigations, at least at the investigation stage, give my office authority to use and issue grand jury subpoenas, use the grand jury as an investigative tool in the local county where the fraud is alleged to have occurred. These are common sense reforms that I think that nobody could rationally oppose. Chairman Gross, Chairman Romachuk, thank you again for allowing me to testify before you today. I'm passionate about this subject, passionate about protecting Ohio's tax dollars, and I will be happy to try to the best of my poor ability to answer any questions you might wish to pose.

Thank you, Chairwoman. Thank you, Attorney General Yost, for your testimony today. I've got a couple questions. Can you describe the GPS technology that's available to you, or is it highly accessible? Do you have your own customized system? What does that look like? And have you had conversations with the prosecutors or association on maybe giving this up? Because I think it makes a lot of sense. Now, on our side in the General Assembly, every time we touch that, it comes flying back pretty quick in a boomerang. So I think we don't want to go there unless that's kind of a conversation had between your peers in that area. Because I think it would make a lot of sense if we would give you more authority in that area, to be honest.

The first, I do not understand myself how the GPS system works. What I know is that while we had it, you could see where the person was. Their car, they had to drive to the house of the person they're providing services for. We could see how long it was there. That record makes it much more difficult to do the fake billing that says I went to five houses but really sat at home. All I know is that it works. With regards to the county prosecuting attorneys, I was a county prosecuting attorney. I was on the board for seven out of the eight years I was a prosecutor. And the answer is no I haven had a conversation with them because I had many conversations and I will tell you what they will say They don like it Which is why I'm careful to say I don't want to take the cases away from them. I just want access to grand jury for purposes of developing the investigation. That doesn't change their prerogatives at all. They can still decline to take the case. we can leave the jurisdictional requirements exactly the same as they are now. Thank you.

Thank you so much. Through the chair. With AI, there's always a concern that it's not going to be able to interpret data properly depending on what information it's given. And I know as a practicing physician that oftentimes AI will deny authorization and then you have to do a peer-to-peer. Is there anything in this formula where you have oversight of the AI decisions or some way to make sure that it's not inaccurately throwing things out or pointing fingers of fraud at people that maybe aren't doing something wrong? Thank you.

Please extend my warmest greetings to your father. I haven't seen him in a long time. I'm glad you asked that question because there is no AI decision. It's an analytical tool only here. More largely, members of this committee, I do not allow the use of AI in the practice of law. We use it for very limited purposes with humans in any decision loop and basically simply for analysis of very large data sets. So we don't use it for drafting. We don't use it for legal research because of the hallucinations. I candidly don't trust it. That being said, it's incredibly useful at doing the analysis on a very large data set. So the way this works is we've got the data set, we ask it to look for a particular kind of thing, and it identifies patterns. those patterns are then sent to an investigator, a human investigator, who then has to pull the billing records, do the interviews, talk to the patients, did this happen? Find out, talk to perhaps even the provider if they're willing to talk and say, gee, do you really work a lot of 18-hour days where you bill 18 full hours? because there are some people that do that. So there are no decisions that are made by AI in my office. They are always vetted, and the final decision authority is with the human being. Thank you.

Thank you so much, Attorney General. I just have a question for you. Are you, I think your fraud detection unit, you have how many? 166. Are you able to send people undercover to walk within the areas that you're concerned about so that you can actually see firsthand? And then secondly completely opposite is the GPS was there a civil reason that they stopped or it just stopped because the legislation said you only get one year Or is there any reason why we just randomly stopped? Taking the second question first, I have no idea.

Committee, any other questions? Representative Craig.

So our team is working every day on these cases, which tend to be complicated. They're basically white-collar corruption in a lot of cases and a lot of instances. The most important thing I've done in the last year is getting the data mining waiver from the feds and implementing AI. I am so impressed with the early results of this. I think it is going to be a complete game changer in this fight. I've outlined several things in my testimony that I hope this committee will advance for consideration as law. I think all of those would help as well. And the only other thing I will say without saying too much about matters that are not yet public is that we do regularly work with the Justice Department and HHS. And there are several things underway that I think will become public later this year that will address some of the concern you're raising about the explosion in providers. And, yeah, I don't think that I'm free to say more than that, except that it helpful to be working jointly with the federal government on these things Committee any other questions Thank you so much Attorney General Yost

Thank you so much.

Well, thank you, Chairman Gross and Chairman Romanchuk, who I just saw had another commitment. Ranking Member Liston and the members of the House and Senate Medicaid committees. Thank you for the opportunity to testify today. Having previously served in the legislature, I appreciate the opportunity to stand on this side of the podium and answer any questions that you might have about our work. The first question that some people ask is, well, why does Medicaid need oversight at all? Well, that probably is self-evident to this group, but Medicaid spends billions of dollars every year. Where there are large sums of government dollars available, we know one thing is true. a lot of people are going to try and figure out how invariably to steal some of it. Anytime you have lots of money, many people involved, complicated rules, you also have risk. Risk of mistakes, risk of waste, and certainly risk of people cheating. The simple message is most providers are honest. Let me say that again. Most people in the system, most of the beneficiaries, most of the providers are honest. But in a program this large, even a small percentage of bad behavior can cost taxpayers millions, and in some cases, billions. So let's get into what we do in the Auditor of State's Office. There is this conception out there that we are the individual who audits beneficiaries. We are not. The Auditor of State's Office is the entity who is the general watchdog over taxpayers. We audit the departments. We look to see that the department has controls in place to stop recipient-level waste, fraud, and abuse. That's our job. We don't run Medicaid. We don't decide who gets benefits. We don't write the Medicaid laws. And generally speaking, we don't investigate beneficiary-level fraud inside of Medicaid. We do have a very small role of doing some limited-a-numbered contract Medicaid provider audits. And I'll have the director of that unit here testifying from our unit, but we're talking about of the tens of thousands, I think what Attorney General Yost just said, 200,000 providers, I think we did 50 Medicaid provider audits. So you see as a percentage, we're not even in the decimal places on the number of provider audits that we do. But those audits are very helpful in us identifying trends. Essentially, we are the person who looks over the logistics and the holistic 40,000-foot analysis of what's going on. So what do we know? Well, with Medicaid spending, we follow the money. We look to see who received Medicaid money, how much money, and for what services and were those services allowed. We audit providers and programs. We do a number of different types of audits. The first is the general state audit. We're going to be releasing, I think on Thursday of this week, this year, annual state audit. We look at the entire state government, all of the agencies, and in doing that, Medicaid as a major component of state government will be part of that audit. One of the things that you're going to hear, and I'm going to bring up my chief deputy auditor and some of our other folks to explain things in more detail to you, but one of the things you're going to hear is this term called materiality. With regard to doing a state level audit, materiality is a threshold that essentially says if you have this kind of risk or this kind of loss, it is material to the overall financial condition of the state. And when you're dealing with a state like Ohio that has very robust, very solid financials, the real question is, would this fact lead to somebody changing the bond rating for the state's financial investments? So materiality with regard to a state audit is very high. I think in Medicaid you're going to hear it's about $1.5 million or so. So if it's less than that, generally it doesn't even get a mention in a state-level audit. That doesn't mean it's not important. As I said to begin with, every penny of waste fraud or abuse is important, and we will go to the end of time trying to end it all. So that is the state audit. You're going to hear from me in just a second that in this state audit that's coming out, we once again found systemic errors in the Medicaid program. Let me tell you just a headline before I get to that. Director Patika, thank you. It is a breath of fresh air having a new director there that is willing to cooperate with our office. I appreciate the work that your staff and your team has done in cooperating and sharing data with us, particularly with regard to the audit that the legislature has asked us to do with regard to the ABD population. That is a change. I'm not saying we didn't have a relationship with the prior director and the prior administration, but it is far more, far more beneficial to have somebody who's going to work as a team and give us access to the data. It doesn't hurt that you were nice enough to give us data access in the last budget as well, giving us direct access to go get the records and to look into the financial, into the systems of the agencies of Ohio as though we stood in the shoes of the entities. That statutory change has been very beneficial to us getting access to data. So let's talk about that. I'm going to bring up in just a second my chief deputy auditor, who can talk more in detail. But here's one of the things we found. These numbers are not impressive. We continue to see that Medicaid is making some of the same mistakes over and over again. We have done a number of audits besides the state audit that have consistently identified flaws in things like program participation and program membership. It would be nice to say that once we find a mistake or an error, that they fix it. Unfortunately, that's really not what we found. On the areas that we test, and let me talk just a second about testing. When we go in and look at a program or part of an audit, we do a limited subset of tests. We pull an actuarially significant or an accounting significant number of tests, but if we're looking at a big program, we are not testing thousands. We're testing hundreds of different transactions. And from those transactions, we pull them randomly to determine whether or not we're seeing a pattern, whether or not we're seeing the entity following its own program controls to see whether or not there's a risk. And in this case, we tested, and we found about a 15.6%, if I remembering correct error rate on eligibility participation inside of Medicaid Now what does that mean That mean on the sample that we looked at we found a different series of error rates Now some of them were dead people that were still on the rolls. Some of them were other type of errors. But is 16, 15.6% something that's significant? Well, in a program as large as Medicaid, you bet your boots it is. Now I will be the first to tell you that you can't literally extrapolate losses here with a high degree of confidence. But if you could, and you did literally extrapolate, a 16%, a 15.6% error rate could be as much as $4.4 billion. Let me say that again, $4.4 billion. If you did another measure based on what we found to be the error rate over that subset and extrapolated that, it would be $800 million. So $800 million to $4 billion is real money. It's real money for Bob and Betty Buckeye, who we all work for, and it's real money that we want to see get fixed. And frankly, it's real money that Medicaid should be taking steps to avoid having any type of error rate. We have done a number of Medicaid reviews in the past, and we are currently doing one more. the Medicaid benefits system for ABD is something that we're currently undergoing and when we get results that I can share with you I'm happy to come back and talk about it because that was an audit that we did at your request. But one of the other areas that we have a great deal of concern is home health care. We are seeing some data anomalies in home health care that is very, very troubling. I'm just going to give you the high level because, candidly, what we have is data anomalies. I can't lead from... I can't correlate from causation to correlation or correlation to causation with any degree of confidence. And so I've got to give you that caveat. We know in this world when you're looking at data, you can't say just because there's a correlation in these numbers that that means there's causation. But the numbers are important and they need to be followed up on. Nearly 40% of Medicaid's $1.6 billion in home health care is spent in Franklin County, Ohio. Let me say that again. One county, 40% of home health care. That's more than twice the rate of spending as compared to Cuyahoga County. In fact, Cuyahoga County, with roughly the same number of Medicaid precipitants and a similar age demographic, spends 14%. Of that $1.6 billion, two zip codes off of Morris Road constitute a very large percentage. Quick facts. Franklin County has roughly 30% of Ohio's home health care registered agencies. 30%. They are getting roughly 38% of the public dollars spent in home health care. 41% of that 38% is spent in a 4-mile radius roughly in two zip codes, the 43229 and the 43231 zip codes. Now, I'm going out of my way to say correlation doesn't equal causation. Are there anomalies? Absolutely. What does that data mean? It's going to take more review. but I do know this that Franklin County 60 plus population is roughly spending 3750 ahead pure counties are spending between to So you seeing roughly three to four times the spend on home health care Franklin County Medicaid recipients, roughly $1,400. Peer counties are between $400 and $600. A significant uptick in spending. Again, we're looking at the data. Data is the data. What's leading to that is a different question, and I'm not prepared to talk about it. I would encourage Medicaid to do more analysis. And this is a good time for me to give a shout-out to the Mufuku unit. Attorney General Rios is spot on. Ohio's Mufuku unit is one of the best in the country. They do really good work. We refer things to Mufuku on a regular basis from our Medicaid division, and candidly, they do a good job running those to ground and landing the plane. And so that leads me with this last bit of information. In the auditor's office, it's one of the few areas where we don't have any direct authority with regard to prosecuting fraud. I'm good with that. We have enough things that we're leading and doing on. But we did establish a hotline for public beneficiary fraud this year, So you can still call the 1-866-FRAWD-OH hotline, 1-866-FRAWD-OH, and report Medicaid or other beneficiary fraud. We will refer those to the appropriate entity, whether it's Medicaid, whether it's MFUCO, whether it's the prosecutor or other entities. You can also go to OhioAuditor.gov and look at that information. I've got a lot more stuff I can talk about and a lot more numbers I can give you. But before I do that, let me bring up three individuals who are really the stars in our program. First is Tiffany Ridenbaugh. Tiffany is our chief deputy auditor. Tiffany, stand up. You're coming up here. Tiffany is the chief deputy auditor for the Auditor State's Office. Prior to that appointment, she served as the chief forensic auditor of our special investigations unit, where she led high-stake investigations into fraud and financial misconduct. Tiffany is not only a certified public accountant. She is a certified fraud examiner, a certified government financial manager, and brings deep expertise into uncovering complex financial wrongdoing transactions. Tiffany, let me go ahead and interview the other two and then let you guys do your presentation, if that's fair. Mike Schmidt is the chief auditor for our Medicaid contract audit division. Mike serves as the chief auditor for our version of our Medicaid contract audit team. That's our division that contracts with Medicaid to do those limited number of provider audits. He oversees audits that safeguard Ohio's Medicaid program from fraud, waste, and abuse. Before leading MCA, Mike specialized in Medicaid financial audits for the state of Ohio. He is also a certified fraud examiner, bringing disciplined approach to identifying and addressing potential fraud risk. And then finally, Emily Redman. She's the deputy director of our Ohio performance team. That's our performance audit division. Emily has held a variety of roles within state government and currently serves as the deputy director of our higher performance team, overseeing the state agency and higher education performance audit teams. A performance audit can be designed to increase customer satisfaction, reduce costs, align operations with mission strategy, and to improve the efficiency and effectiveness of an organization in its program. Tiffany, Mike, and Emily will now, with your permission, Madam Chair, present a more in-depth view of what exactly we've been looking at. So go ahead, Tiffany.

chair gross by sure om check regular listen my name is Mike Schmidt as otter paper said I'm the chief of our Medicaid contract section so I'm going to give you kind of an overview of what our section does and how we interact with our partners we have a dedicated staff of 17 auditors that kind of take a targeted approach in two key areas one of the key areas is over cost report audits so those audits are based on contracts with the Ohio Department of Medicaid and the Ohio Department of Developmental Disabilities We spend about 28 audit hours as a group doing our work and those cost report hours are included in this and those are over intermediate care facilities, passport agencies, county boards of developmental disabilities and those associated councils of government. The second key area we focus on is the the Medicaid provider compliance audits as Attorney General Yost talked about there was over 200,000 active providers so there's a lot there we have limited resources really to kind of dig into that gap with such a large number of providers in calendar year 25 we released 55 cost report audits identifying 32,000 in findings on the compliance side only 47 reports but we identified four point $5 million in improper payments and reported those to the department. Since 2019, 231 reports were released for $20 million. So you can see that it's paying off just the resources to do all the work. You know, we need a little bit more. Also, I just want to kind of talk about some common areas that we find. A lot of times we get some questions. What are some things you find? So rather than read a bullet list to you, I will kind of give an example of a home health agency that we found in the Columbus area. But before I do that, I just want to kind of reiterate what we don't do. We don't focus on individual recipient eligibility. We don't look at quality of service delivery, and we don't look at medical necessity. Those aren't in our purviews, so we do not do that when we do our examination. So getting back to an example here from a home health agency out of the Columbus area, we identified 30 providers, 30 aides that are rendered services, and we do check to make sure they're qualified. In 15 instances, we noted 15 providers didn't even have the basic first aid requirement met, but they still rendered the service, right? So super important that our providers are certified and maintain the qualifications that are needed. This provider was also unable to provide service documentation in some instances, and even when they did, sometimes service documentation didn't match up with the service that was rendered and the claim that was paid, so just raising more red flags. And also we noted documentation that indicated one continuous shift was performed, however they billed two different services to Medicaid, so we're just overbilling for no reason. Next, we identified plans of care that either weren't signed by the physician or just weren't even available to us. Finally, we noted instances when the units billed to Medicaid exceeded what the service documentation had indicated. So just more overbilling by the provider to get a little more money. So just kind of summarize what we did. We examined 326 payments in this provider audit. Of those, 135 were identified, had noncompliance there. That's 41%. Our total improper payment was a little bit over $8,600. So in the grand scheme of things, it looks small, but when you take that 40%, over a three-year period, this provider had payments received about $8.5 million. So we can't play that game because extrapolation is not maybe appropriate in this scenario, but if you would do the math, that's about $3.5 million if we took that 40%. So we have to be careful. As Tiffany said, we're a reporting agency, and we have auditing standards to follow, so we don't necessarily extrapolate. but as Auditor Haber said to do some of the math it kind of eye to see potentially what we coming across So now that we use this example kind of just to describe the impact and what we do as a reporting agency we report all of our findings to the department for further review and they kind of take it from there as far as collecting any overpayments any technical assistance or educational opportunities as they see fit So that's probably the biggest thing is these recoveries help protect the financial integrity of the program by collecting any improper payments. Also is making referrals to the appropriate agency. We are well positioned to submit referrals to the Ohio Attorney General's office as needed. And these referrals really just broaden the oversight beyond the examination that we perform. It really allows us an opportunity to maybe open that provider up to additional regulatory action or different purview. and last maybe the most important it was kind of in touch on a little bit is the transparency all of our reports are available on our website for the public to view the media to view and really just helps hold those providers accountable to you may potentially even drive reform finally like give an example and a shout out to the department as well for working with us in collaboration with a provider who wouldn't let us conduct an audit they were continuing to fight us a little bit as far as our authority and our ability to do that so after some months of trying to convince the provider we are allowed to audit them we reached out to department for assistance and they had sent a letter on our behalf and we are happy to report that they have provided some records and we're currently conducting the examination but I think without that it's cooperation we would not have got that provider to provide us some of the information. Now that I talked about some common errors and impacts, I'm going to discuss a little bit about some of the past initiatives. I know we've kind of touched on a few of them here. So I'm going to go over the last five public interest audits. I'll kind of skim through them because I know some of them have been touched in some format here. Links have been provided to you as well in case you'd like to reread through these. The 2020 eligibility audit, we estimated $455 million in potential loss tied to the Ohio Benefits System. That audit from 2020, the auditors tested eligibility determinations of 324 recipients over 27 counties and found that 4.9% of those received benefits were in fact ineligible. So this report highlighted the weaknesses of the Ohio Benefits System at the time that were used to make these eligibility determinations and to manage the alerts. However, as we've kind of heard from before, this census public interest report's been issued, findings regarding the alerts continue to be noted in other state reports. In 2022, we identified or released a report over improper capitation payments that identified $118.5 million in payments to incarcerated, deceased, or duplicate enrollees. Since this public interest report was issued, findings over deceased individuals continues to be a theme that we've seen across other ALS reports. The next one is a 2022 public assistance reporting system audit that reviewed the Ohio Department of Medicaid's handling of public assistance alerts for potential duplicate benefits across two or more states. The audit identified 42,000 Ohio recipients that had matching data assistance enrollments in one or more states, and proper payments were estimated to be $5.3 million to $24.5 million annually. and as previously mentioned the 2024 concurrent enrollment report that found more than 124,000 individuals were enrolled in Ohio Medicaid and another state simultaneously with the potential impact to exceed 200 million dollars next next one we talked about was the 2024 electronic visit verification report that found 56 of the home care services were not processed through the electronic visit verification system with the estimated potential impact to $1.1 billion in claims. This was a new requirement, and based on discussion with the department, they were working through our recommendations and being phased in, as you heard earlier from the director. Now moving on to some of the current initiatives. At the request of the General Assembly, we are taking on the age-blind and disabled aid category. We are working through that. Our work is underway in reviewing that population. The population is just short of 500,000 individuals, so a pretty tall task for us to kind of tackle. So we're currently working through that large population to identify what's an efficient method manner to perform our work and our testing to make sure the proper requirements were met. Data has been provided to ALS. It's a little bit inconsistent for some of the resources, but the department's been working with us to collaborate with this data and has allowed us to work through some of these inconsistencies. Now I'm going to hand it over to our performance team to talk about their next generation initiative. Yeah, thanks, Mike. As Auditor Faber said, I'm Emily Redman. I'm the Deputy Director of the Ohio Performance Team, overseeing the state agency and higher ed channels. We also have K-12 and local government channels, so we have 44 staff members who work in those four channels and work on our performance audits. Different from financial audit, we have a little more flexibility in what we're looking at. We're looking at operations. We're looking at processes. We're not just looking at the numbers per se, but we can look at the numbers obviously too. So that is some nice flexibility that we have. I'm here today because in the budget bill, as you are probably aware, there was an amendment to look at the next generation system within Medicaid. There were eight detailed areas within that and then flexibility for us to look at anything else that we wanted to. those eight areas mentioned in the budget bill will be contained somehow within our five scope areas that we established that are a little broader umbrellas that we're putting those programs within, right? So the five scope areas that we're looking at are strategic planning and program evaluation, program and financial forecasting, county performance variation, state contract management, and provider claim processing and interactions. So within those, we'll look at all the other eight areas that were in the budget bill. So for example, like Ohio RISE is a newer program. Not a ton of data for us to look at, but we're going to look at that within program evaluation, looking at KPIs and other things that they're doing within the department. This audit will fall under our 117.46 authority, which means the agency will have implementation and reporting requirements to it. So when we issue recommendations, there is a section in code that requires implementation or report out as to why they're not implementing our recommendations. So we check in annually with state agencies and institutions of higher education to make sure they're implementing or reporting why not. Part of this scope area, that county performance variation, will tie into ABD. So to be more efficient within the office as our auditors travel to 20 counties that we've picked based on certain criteria like enrollment numbers or case accuracy or staffing or other things that we've seen within the county variations, as they travel, they will be doing process mapping. And part of that process mapping will include the ABD process. and other eligibility determination questions. So we'll be working with Mike's team on that. The budget bill said to release by December of 2027. We are looking at releasing our performance audit this fall, so much earlier than the budget bill required. So, and with that, I think I will turn it back over to the auditor. Thank you. I wanted you to get a flavor of the type of things we've got going on. As you figured out, we do a lot of stuff. I do, again, just want to reiterate that Medicaid has been, in the past, sometimes difficult for us to work with. That isn't the case now, and I think the director deserves a lot of credit for working with our team and having his team work with our team in a collaborative. But I also want to give you a shout-out. When you said we have access to their data, you meant it. One of the things that came out of this, and I'll just build around, one of the things that Attorney General Yost asked for is subpoena authority. I have subpoena authority. And so when our Medicaid division ran into a situation to where a provider didn't want to give us records, we issued a subpoena. Normally, you would think we would just go and enforce a subpoena. That's how we would normally do it, go to court, file an action, and start enforcing the subpoena. We said, no, let's work with Medicaid. Medicaid, in that case, sent a letter reminding the provider that their provider agreement requires them to provide us data when we ask for it. And Medicaid started the process to end them being a Medicaid provider. Nothing gets an attention of a provider like losing the ability to do Medicaid work. And that work from the Medicaid department worked, frankly, much more efficient than our subpoena. And so we got the information, and now we're digging into it to figure out where it's going. So I did want to say that and buttress that in. The other thing, look, Attorney General Yost's office is very good when we have data and get that over to them. They will run stuff to ground for us very effectively. So with that, it's a good time to open it up for questions.

Thank you, ladies and gentlemen, both of you, and Representative Stevens. Thank you, Chair. Thank you for your presentation. I really appreciate the data and the info. And I wanted to go back and make sure I heard you right when you talked about the couple of zip codes here in Franklin County and then some of the error rates. If you could reiterate that.

Yes, Representative. Thank you, Chair. So it could be an anomaly, but there could also be a reason. My question is, does the Auditor of State, Attorney General, Department of Medicaid, I know there's a lot of three very big organizations, obviously Medicaid. It seems like it's, even in the best of times, it's a little cumbersome. Do we need to have some sort of ability to, when we see, when the auditor is able to identify something, do you need some more tools to go after that?

Representative Lett. Thank you, Chair. Thanks so much for your testimony. I just had a quick question about the 2024 audit that had findings in concurrent enrollment. It's saying that 124,000 individuals enrolled in Ohio and another state simultaneously. My question is, did you find that there was billing happening simultaneously in Ohio as well as another state? How did you comprise that $200 million? I know that capitation payments are certainly a portion of it, but I would be willing to guess that the entire $200 million does not consist of capitation payments alone.

Yeah, nothing really to expand on there. He's exactly right. Yeah, thank you. Boy, they've trained me well. Thank you. No follow-up, Jeff. All right, thank you.

I think the answer is yes and no, but go ahead.

Philip, through the chairwoman, chairperson. So then how are they sampled? It's sounding like it's not a random sample. It's a targeted sample where you think that there's an issue.

More questions? Yeah, absolutely. All right, thank you. And I'm sorry, I have another topic. So just to follow up, it's a $5 million contract, we're saying? Did I hear you say that? You said there's a $5 million contract to evaluate. Oh, you're talking about the ABD side.

All right. Thank you. So through the Chairwoman. Then moving to the estimates, I mean, obviously there's a lot of big numbers, so I want to make sure I understand some of the methodology a little bit better. I know the EVV audit, as you mentioned, that's a new program that, quite frankly, I think isn't fully rolled out. So I worry about relying on that $1.1 billion. But the other numbers were we're doing estimated payments for enrollees that are deceased or in other states. Can you talk a little bit more about how you sort of get that information? Are they surveys? Are these actual people identified and pulled out so you can say, hey, it's this number of individuals?

Oh no one more Okay All right Well so I guess I will choose because I have two As you look at this and we say, okay, these are payments that we identify, and we talk about the payments are going to the managed care organizations. What sort of engagement do they have in this process of identifying when they're being overpaid, right? This is not individuals getting the benefit. it's the MCOs receiving all these funds. Tell me how they're involved or what interactions you guys have to make sure that these data are as accurate as possible. Sure.

Okay. Thank you. Okay. Thank you. Senator. Representative Barhorse.

Madam Chair, Representative, the short answer is yes. We are working collaboratively with other states, have been for a long time, and certainly with the federal government. In fact, when we started hearing about some of the things that were going on in other states, we actually contacted the new U.S. Attorney's Office and put together a working group. And the short answer is we are working where we think that's appropriate. And we are certainly working very closely with the folks in D.C., and they have given us access to some data that, frankly, we have never had access to before. to help us run some things to ground. And some of that is, again, you can get, as the senator was mentioning, these numbers can get very overwhelming at some point, and how you do things and where the numbers go from. When you're dealing with 50 states and 50 different state systems, it can probably be equally overwhelming. And so when one of the things, I'll just give you one example. we identified that one of the problems Ohio Medicaid system has is that the system is flagging a lot of alerts. If you had time and resources to follow every one of those alerts, there's no way the local counties do. I mean, they just can't. You would probably eliminate a lot of beneficiaries that should be eliminated. The problem is that we found that it unrealistic to do that You would frankly not do that There are some counties that do it far better than others But one of the questions when you look at this from a national perspective, the feds don't care. They come in and say, you guys should have flagged this. You might have, but nobody took action. What did you do to follow up to make sure that action is taken? And the risk that hasn't happened, but that we all worry a lot about, is if at some point the federal government comes in, and one of the things we do in our audit is we do the federal compliance audit. That's why we flag things. The federal government could come in and say, Ohio, you're not doing what you're supposed to do. We're going to claw back some money. And goodness knows if that happens, our system folds. because we are essentially a system that is predicated on having a lot of federal money with a relatively smaller amount of state money to pay for all of these claims that Ohioans in a lot of cases have come to depend on for their health care, as I think the representative mentioned. And so the question is how do you balance that to make sure we're doing what we're supposed to do at the same time making sure it's a practical, manageable system.

I think the answer is it depends. I'm sure Medicaid gives guidance. the problem is if you're the director in Mercer County, where I live, where you used to live, the fact of the matter is that your director is going to have a much different set of priorities and a much different set of abilities and staff to look at some things than somebody who's in Cuyahoga County based on the volume and the other issues. So this is an issue that is going to have to get fixed. And if it doesn't get fixed, we run the risk at some point of having other issues come to bear.

You're beyond my bandwidth to tell you how to fix a multibillion-dollar IT system. But there are a band of discussions. One question is we have a state-county-administered system. There's some discussion of just doing it all at the state. I'm not sure that's the right answer. I generally like, as we like to be the laboratories of democracy for the federal government, the states, I kind of think counties. So let's find a county who does it really well and figure out what they're doing right and what they need to do. Let's have the conversation giving Medicaid the support that the director, I think, is utilizing to try and figure out where their software and their systems work and where their software and their systems don't work. So ultimately, that's not an auditor question. I'd love to say this, that auditors, we find problems. Somebody else gets to figure out the solution. But in the end, we know this is a problem, and this is a problem that is causing Ohio to have people on the program that shouldn't be.

Thank you. Committee, any other questions? All right, it's me. Thank you. I still have one more. Thank you to Tiffany, Mike, and Emily and Auditor for being here today. My question, a little bit different. I appreciate all that you do. I hear a trend in home health. We hear a trend I know the alerts you talking about I assuming are Paris alerts right The Paris alert system and that a federal system and we do struggle with that right Director Partika It's a lot of double and triple work for our local JFS, ODJFS agencies at the county level. Mine's a little bit different. I would like to ask you, I just had a comment this past week about some people that are potentially billing for autism scholarships as well as Medicaid at the very same time. If something like that were to occur or is occurring in the state, would that be another audit that we would request through the auditor and also through Medicaid? and how would it work that both agencies could work together to come up with what is actually going? We have autism scholarships, and so, Emily, this is kind of why it's you, right? And then it's Medicaid, where I'm hearing that some of the schools are billing for Medicaid at the very same time that we're also paying autism scholarships. Do you, I don't mean to put you on the spot, but these kinds of think tanks and opportunities for us to meet together, bring us together to spur new conversations. This is a case where both two agencies together, if there was a fraud found, then that would be returned to the AG, right? And we work together. What would be your recommendation for that? Emily?

Thank you very much, Auditor. And this is a question, Director Partik, about related to the auditor's audit of duplicate payments. I think we discussed this maybe in my office. I just wanted to bring it out publicly.

Again, this is in your world, so I'll let you answer. But my understanding was that that has partially been fixed by the Trump administration, that there is a national database. But I'll ask you, this is your world.

Thank you so much. I appreciate all three of you, Director Partika, AG Yost, and Auditor Faber and your team. I love how we're working together. I see fixes for the Ohio taxpayer, and I appreciate your time. Are there any questions? Seeing no further business for the joint meeting of the Standing House and Senate Medicaid Committees, this committee stands adjourned.