Activities and oversight

Audit process

The following items chart the processes used by HCA.

• Audit process
• Sampling and extrapolation process

Federal audits and reviews

Payment Error Rate Measurement (PERM) review

PERM uses a 17-state rotational approach to measure improper payments in the Medicaid and Children's Health Insurance Program (CHIP) for the 50 states and the District of Columbia over a three-year period. As a result, each state is measured once every three years. The state will notify providers who are selected to be part of the PERM review. Providers will be contacted by the PERM contractor with a request for records.

For more information, see our frequently asked questions (FAQ) about PERM.

Federal contractor audits

UPIC Unified Program Integrity Contractor (UPIC)

In February 2006, the Deficit Reduction Act (DRA) of 2005 was signed into law and created the Medicaid Integrity Program (MIP) under section 1936 of the Social Security Act (the Act). CMS has two broad responsibilities under the MIP.

• To hire contractors to:
  • Review Medicaid provider activities.
  • Audit claims.
  • Identify overpayments.
  • Educate providers and others on Medicaid program integrity issues.
• To provide effective support and assistance to states in their efforts to combat Medicaid provider fraud and abuse.

The Western UPIC was awarded to Qlarant in early 2018. UPIC works with the HCA's Section of Program Integrity (PI). They conduct audits that examine payments made to individuals or organizations providing services or items. In the course of these audits, medical documentation and other supporting information will be reviewed for paid Medicaid claims of services or items furnished. As appropriate, the audits may result in the identification of potential overpayments.

Recovery Audit Contractor (RAC) audits

In 2012, HCA selected CGI Federal as its Medicaid Recovery Audit Contractor in a new federal effort to review Medicaid payments and identify payment errors - both overpayments and underpayments - as part of the Affordable Care Act. A key feature of the Recovery Audit Contractor program is that its reviews will be based on the state's data, not federal extracts. The state's contract with CGI Federal ended in June 2014. The HCA currently has an exception from CMS to evaluate the procurement.

False claim and whistleblower education

The DRA applies to any entity receiving or making annual Medicaid payments of $5 million or more. Entities are required to establish and adopt written policies about federal and state false claims laws for all its employees, contractors, and agents.

Scope

All programs and providers receiving Medicaid and Medical Assistance funding are subject to the False Claims Act, provided the provider receives $5,000,000 in payments annually, under a single TIN/FEIN (Tax Identification Number/Federal Employer Identification Number). These policies and procedures are primarily used and enforced by HCA's Section of Program Integrity and the DRA program manager.

Each year HCA's DRA program manager completes data runs to show which providers have made $5 million or more, under one TIN/FEIN. Providers are then notified to complete their attestation form and to send them to the agency.

A sample of these identified providers is also selected to send in copies of their policies and/or teaching materials regarding the False Claims Act to ensure they have the required policies in place.

State False Claims Act

In 2012, the Washington State Legislature passed the Medicaid False Claims Act, which funded two specialized positions with the Health Care Authority (HCA). HCA investigators follow leads, mine data, and prepare fraud referrals for the Medicaid Fraud Control Division (MFCD) of the Attorney General's Office, for both civil and criminal prosecution.

Site visits

HCA performs unannounced on-site visits of moderate or high-risk providers when requesting enrollment in the Apple Health (Medicaid) program (Title 42 Part 455). We also perform unannounced on-site visits of currently enrolled moderate or high-risk providers during the re-validation process. A list of moderate to high risk provider specialties is listed below.

Additional information regarding site visits.

Other Provider Preventable Conditions (OPPC) notification

Providers must notify the Health Care Authority (HCA) in writing within 45 days of confirming OPPC. 

To notify HCA, complete the OPPC notification form (in Word or pdf format) and fax or mail it to:

Health Care Authority
Attn: Section of Program Integrity
626 8th Avenue Southeast
PO Box 45503 Olympia, WA 98504-5503

Fax: 360-586-0212