16 November Changes to Government Healthcare November 16, 2016By Jon Coss - Blog Manager General EITC, medicaid, Medicare, Obamacare, tax fraud 0 As a company, Pondera is closely following the comments coming from the incoming administration about how they are approaching government efficiency and entitlement reform. Paul Ryan, in particular, has made several statements about the Affordable Care Act (Obamacare), Medicare, and Medicaid. This post provides some of our thoughts around how these changes may affect fraud, waste, and abuse.While changes are clearly coming to Obamacare, this week Speaker Ryan also hinted at potential changes to Medicare and Medicaid. In Medicaid, where Pondera works with multiple states to detect fraud, Ryan hinted that the administration would consider offering tax credits in place of expanding the number of Medicaid recipients. This is necessary because Medicaid expansion, a byproduct of Obamacare, shares its fate with Obamacare.While the tax credit idea is interesting, it is certainly not without its own problems. Tax credits, which unlike tax deductions offer dollar-for-dollar savings off bottom line taxes owed, are an attractive target for fraudsters. In fact, the Earned Income Tax Credit (EITC), which offers tax breaks to low income Americans, suffers from a 23.8% improper payment rate in 2016. This is one of the highest rates for any government program translating to $15.6 billion in waste.On the surface, it seems the administration’s idea may shift much or all of the fraud problems in Medicaid expansion from health departments to state tax collection agencies. Here is one thing we can be sure of though: as long as there are large amounts of money in these programs, there will be bad actors who will attempt to defraud the system. And experience shows us that they will create innovative and technologically-advanced methods to support their efforts. Related Posts A Reminder of Government’s Important Role in Helping Americans Regular readers of this blog know that we often focus our comments on the fraud and abuses in government subsidy programs. Our intent is almost always to point out solutions that can make these programs more effective, rather than to question the existence of the programs altogether. In fact, most Pondera employees worked for government agencies in the past and recognize the good that many programs deliver.The recent fires in California provide an example of government programs helping Americans in need. The fires, which tore through California’s wine country, including Napa and Sonoma, claimed over 40 lives and 7,000 structures, and displaced nearly 100,000 people. Entire neighborhoods were destroyed leaving families scrambling for shelter and food.A number of government agencies sprang into action to help those affected by the disaster. While most Americans are somewhat familiar with, for example, how FEMA responds to disasters, other efforts are less obvious but very important.For example, I took note of the combined efforts of the United States Department of Agriculture (USDA) and the California Department of Social Services (CDSS) to provide emergency food assistance to local residents. Using the Disaster Supplemental Nutrition Assistance Program (D-SNAP), CDSS offered a month of food benefits to those who qualify. This is in addition to other waivers such as allowing existing SNAP beneficiaries to purchase hot foods (many lost their homes and by extension their ability to prepare foods).Events like the fires in California, while heartbreaking, also provide us with a reminder of the important work done by federal and state government agencies. This is also a time to remember the important work that agencies do throughout the year to support Americans who truly need our assistance. We believe our job at Pondera is to help governments deliver better services by driving fraud, waste, and abuse out of their programs. The Internet Changes Everything Way back in 2006, I read an article in the Harvard Business Review that described how the Internet had changed the sales profession. One key observation dealt with the “de-coupling” of the sales cycle from the buying cycle. Prior to the Internet, buyers had to contact vendors for information on their products. Today, buyers do their own research and successful salespeople need to unhinge preexisting customer assumptions prior to starting their sales process.I believe that the Internet has had an even greater impact on fraud in government benefit programs. Government agencies are under constant pressure to move applications, certifications, and other processes on line to make them more convenient for citizens and businesses. This makes perfect sense because, after all, government exists to serve the needs of the citizens. Unfortunately, moving these processes to the Internet dramatically increases the incidence of fraud.The Internet provides a degree of anonymity that makes it extremely attractive to fraudsters. The number of fictitious businesses and “ghost beneficiaries” in government programs has exploded in recent years. Many of our customers deal with applications associated with out-of-state or out-of-country IP addresses. Others come from deceased or incarcerated individuals. Still others show indicators of originating in “sweat shops” that create bulk applications and claims.Just like the salesman that had to adjust to the new sales cycle, it’s important that government program integrity staff adjust to the changing fraud landscape. IP spoofing, anonymous email services, and the wide availability of stolen identities are realities in the post-Internet fraud market. Relying solely on the traditional detection and investigation techniques is no different than the sales person who thinks their prospect hasn’t done any of their own research. How Startups Benefit Government What a delight it was to read a commentary in Government Technology magazine by Rebecca Woodbury, a Senior Management Analyst with the city of San Rafael, California. In the article, Rebecca recounts her experiences working with technology startups and the benefits to the city of moving beyond a small set of traditional providers.Rebecca argues that startups offer “simple and intuitive interfaces, don’t require costly implementation fees or long-term contracts, embody the spirit of continuous improvement, and have their eyes keenly on the future.” She goes on to state that these benefits are far more important than “the number of years a company has existed or the number of clients they have.” And she even provides ways to mitigate the risks associated with startups such as avoiding long term contracts.Right on Rebecca! While Pondera is no longer considered a startup and we can meet the stringent financial and customer qualification requirements in public sector bids, we work hard to hold on to the EXACT list of benefits Rebecca articulated. And when Pondera was a startup, we counted on people recognizing those benefits. That’s why we would get so frustrated when we would read RFPs that asked for “innovative solutions” but required that they be implemented for at least five years! In the age of cloud computing and Agile development, the gap between business needs and archaic procurement policies has grown into a gaping canyon.So, at the risk of inviting competitors into our market, I applaud Rebecca’s efforts and those of similar public servants who recognize that nimble, innovative startups offer compelling alternatives to large, established IT companies. I also know that competition makes all companies better. In the end, isn’t that what government wants in its partners? New Data on Problematic Government Programs One of my favorite websites, paymentaccuracy.gov, has received a number of updates which may provide some insight into the current administration’s priorities. If you haven’t done so already, I encourage you to visit the site as it provides improper payment information on the government’s high-priority programs: those that report over $750 million of improper payments in a year or have not established or reported on their error rates.The current version of the site includes many of the usual suspects including Medicaid ($36.3 billion in errors), Medicare fee-for-service ($41.1 billion), and the Earned Income Tax Credit ($16.8 billion with a whopping 24% error rate). SNAP continues to be listed but still does not provide relative numbers because of inaccurate state reporting—something we have discussed in previous posts.Other items of note are the inclusion of three Veterans Affairs programs for Disability Compensation, Community Care, and Purchased Long Term Services and Support. While the .59% error rate on the $64 billion Disability Compensation plan appears surprisingly low, the 75.86% error rate for the $4.7 billion Community Care program is likely the result of new reporting requirements… at least I genuinely hope so.Other high error-rate programs include school nutrition services (both breakfast and lunch), student loan programs, and Unemployment Insurance which ticked up to 11.65% this year.Regardless of political leanings, I think we can all agree that we want our tax dollars going to those who need them the most. And the transparency provided by paymentaccuracy.gov is a great step toward this goal. My hope is that the government will continue to provide easy access to this information. I am still disappointed each time I visit the expectmore.gov website (which reports on program performance, not just fraud, waste, and abuse) where I see the following message:“Expect More.gov was an initiative of the George W. Bush administration. This website has been archived and is posted here as an historical resource. It has not been updated since the end of 2008 and links to many external websites and some internal pages will not work.” Buried Pentagon Report Leads to Questions for Other Government Agencies Earlier this year, four government agencies – Commerce, Health and Human Services, Energy, and the Environmental Protection Agency—received letters from congress directing them to provide documents and comments detailing their efforts to “identify waste and… to achieve budget savings in the next five years.” The letter referenced a report from the Pentagon that identified a “clear path” to saving over $125 billion over five years, which was subsequently suppressed because of the dramatic findings.The Washington Post, which was mentioned in the letter from Congress, exposed the Pentagon’s internal study in December 2016. The Post explained the reason the Pentagon buried the study was that they feared Congress would cut their budget if they knew of the waste. Incredibly, the “clear path” to savings did not even require layoffs. Rather it would use attrition, early retirements, reductions in expensive contractors, and modern technology to streamline operations.To put the size of the problem in perspective, the study showed that the defense department paid over 1 million back-office staff to support 1.3 million active duty troops (the smallest number of troops since 1940). Thanks to these large numbers, the savings from streamlining could have led to reallocating up to $125 billion for troops and weapons and rebuilding the nation’s aging nuclear arsenal. But apparently, some Pentagon officials decided that protecting against budget cuts was more important.The four agencies who received the letter from Congress have until March 10th to respond. Their response must provide a copy of their internal reports similar to the Pentagon report, lessons learned for their department if they do not have a similar report, and any efforts the department has made to combat waste. Given that these four agency budgets total over $1 trillion, twice that of the Department of Defense, there should be ample opportunities for savings. RFPs: The Devil is in the Details As a company that works with government clients, we spend a tremendous amount of time and money responding to Requests for Proposals (RFPs). We understand that governments use RFPs to ensure competitive bidding processes and to articulate their requirements. However, the process still causes enough angst for prospective bidders that, ironically, it often actually limits competition.We wrote in a previous blog post about the lengthy RFP procurement cycles and their impacts on the final project. Today I’d like to discuss the formats of the RFPs themselves which often cause confusion, leading to large numbers of vendor questions, which in turn leads to delayed timelines and incorrectly submitted bids. I confess that I have never been on the “other side of the table” writing an RFP and I can only imagine how difficult it must be. But I still have one simple suggestion that I wish government agencies would take prior to releasing an RFP.Before releasing an RFP to the vendor community, I suggest that government run an internal “mock” procurement: “release” the bid to a few agency employees and ask them to respond to it. They don’t have to provide actual answers, just an outline so they can make sure they understand what the RFP requires, where responses should go, how the format works, and other structural issues. It’s important that these people had nothing to do with the writing of the RFP document itself because then they’d naturally understand what they intended when they wrote it.Commonly confusing issues we see in RFPs include where to place a Statement of Work (in tables or in text), repeated questions, seemingly mutually exclusive statements or requirements, and “thrown in” requirements that belong in other sections and break up the flow of the response.I think government officials would be amazed at how much confusion and time they could take out of their procurements by performing this simple quality assurance exercise. This would also reduce the number of questions the state would have to respond to and provide more focus on issues of substance rather than administrative or formatting issues. Finally, it would lead to more uniformity of responses allowing governments to evaluate responses for their merit rather than having to search for answers to their requirements. 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