About this transcript: This is a full AI-generated transcript of Congressional hearing: Medicaid fraud risks and oversight from FOX 9 Minneapolis-St. Paul, published June 26, 2026. The transcript contains 20,723 words with timestamps and was generated using Whisper AI.
"The Subcommittee on Oversight and Investigations will now come to order. The chair now recognizes himself for five minutes for an opening statement. Good morning, and welcome to today's hearing titled State Medicaid Program Integrity, Examining Fraud Risks and Oversight Deficiencies. Today's..."
[4:39] The Subcommittee on Oversight and Investigations will now come to order.
[4:43] The chair now recognizes himself for five minutes for an opening statement.
[4:48] Good morning, and welcome to today's hearing titled State Medicaid Program Integrity,
[4:53] Examining Fraud Risks and Oversight Deficiencies.
[4:57] Today's hearing will examine Medicaid program integrity in four states,
[5:03] Minnesota, California, New York, and Ohio.
[5:06] For the first time in years, state Medicaid directors are testifying before Congress
[5:12] to share what they are doing to address rampant fraud in government health care programs.
[5:18] Let me be clear.
[5:20] Fraud is not isolated to these four states.
[5:24] As we have discussed in two previous hearings before this subcommittee,
[5:28] Medicaid fraud is a real problem.
[5:30] It happens in every single state, red and blue,
[5:34] and has been harming patients and draining taxpayer resources for decades.
[5:40] In Minnesota, a recent $90 million Medicaid fraud takedown brought charges in autism therapy services,
[5:48] housing support, home health care, and personal care services.
[5:53] This was just the latest set of charges in ongoing fraud investigations occurring there.
[5:58] In California, a man recently pleaded guilty to $270 million in fraudulent prescription drug claims to Medicaid.
[6:08] Earlier this year, charges were filed against 21 suspects for defrauding Medicaid hospice benefits of $267 million.
[6:18] In New York, $226 million in social adult daycare fraud has been charged in 2026, just so far this year.
[6:28] Remember, millions of dollars have been implicated in non-emergency medical transportation fraud schemes in recent years.
[6:37] In Ohio, a $42 million Medicaid fraud takedown implicated nine defendants
[6:43] in connection with therapeutic behavioral health services for children and young adults.
[6:49] Recently, there were also charges made in connection with hundreds of thousands of dollars in in-home service fraud.
[6:57] These fraud schemes harm patients.
[7:01] When services are billed but not rendered to vulnerable Medicaid recipients who are dependent each and every day on this support,
[7:09] the consequences can be severe.
[7:10] And unfortunately, sometimes those consequences can be fatal.
[7:16] Elderly and disabled patients in need of in-home care do not receive the help that they need to live the lives that they have with dignity.
[7:25] Children who have benefited from essential therapies often don't receive them.
[7:30] Those who rely on transportation assistance to attend medical appointments
[7:34] miss the preventative care and treatments that they need to stay healthy.
[7:39] This morning's hearing is a culmination of months-long investigation led by this subcommittee into Medicaid fraud
[7:47] with the goal of strengthening the program integrity.
[7:50] After two hearings, letters to 11 states requesting documents and information
[7:56] and reviewing over 90,000 pages of documents and information produced to this committee.
[8:02] It is clear that some states are not doing enough to safeguard the Medicaid program,
[8:09] and gaps remain in program integrity requirements that are opening the door far too wide to fraud.
[8:16] Thankfully, fraud is finally getting the attention that it deserves.
[8:21] I commend this administration for surging resources to the war on fraud
[8:25] by forming a task force to eliminate fraud.
[8:29] Additionally, CMS and the Office of the Inspector General are leveraging their authorities
[8:34] to hold states accountable when they are not meeting the mark.
[8:39] We are seeing accountability for the first time in far too long.
[8:44] But more remains to be done.
[8:46] We can no longer tolerate criminals taking advantage of the Medicaid system.
[8:51] Fraud is not and should not be the cost of doing business.
[8:54] It is preventable, and we have a duty to help rein it in.
[8:59] It is no longer sufficient to do the bare minimum.
[9:03] States must rise to the occasion and tackle fraud head-on.
[9:07] Our Medicaid program and the patients that rely on that to be healthy each and every day of their lives,
[9:15] they depend on it.
[9:17] I want to thank all of our witnesses for being here today.
[9:19] We look forward to hearing from you and learning more about the steps that your state is currently taking to address Medicaid fraud.
[9:28] With that, I now recognize our ranking member of the subcommittee, Ms. Clark, for her opening statement.
[9:34] Thank you very much, Mr. Chairman, and I'm glad to have another opportunity in the subcommittee
[9:39] to discuss the partisan actions that the Trump administration has taken against state Medicaid programs
[9:45] under the guise of fighting fraud.
[9:48] Democrats have been raising concerns about CMS's threats of funding cuts to blue states,
[9:53] which are destabilizing programs and risk further cuts to health care in states led by Democratic governors,
[10:00] leaders who President Trump sees as political enemies.
[10:03] The administration's partisan motivations are clear.
[10:07] In January, amidst terror and chaos in Minnesota caused by the Trump administration,
[10:14] CMS announced it would withhold up to $2 billion from 14 of Minnesota's health care services.
[10:23] Days later, on the heels of the killing of an innocent American citizen by ICE agents,
[10:29] President Trump threatened Minnesota with a, quote,
[10:32] day of reckoning and retribution, unquote.
[10:35] When CMS Deputy Administrator Brandt testified before this subcommittee in March,
[10:41] I asked her when a hearing would be scheduled on CMS's decision
[10:46] to withhold more than $500 million in quarterly Medicaid funding from Minnesota.
[10:52] She said that CMS had been stayed from scheduling a hearing, which proved to be entirely false.
[10:58] When we asked for correction or clarification of her false testimony,
[11:04] Deputy Administrator Brandt did not provide one.
[11:07] We cannot conduct oversight if CMS is going to lie about its actions.
[11:14] CMS has also deferred $350 million in Medicaid funding from Minnesota
[11:19] for two consecutive quarters in sweeping cuts to entire service categories,
[11:25] but has not provided Minnesota with a meaningful or consistent guidance on how to address CMS's concerns.
[11:34] In California, CMS has put $1.3 billion in Medicaid funding in jeopardy
[11:40] through a deferral for home health care service payments.
[11:44] CMS Administrator Oz proudly announced that this was the largest deferral ever by the agency.
[11:52] He fails to acknowledge the impact that these overbroad, indiscriminate actions will have,
[11:58] and he has refused to accept California's explanations for the growth in those services,
[12:03] which are due to longstanding efforts by the federal government and states
[12:07] to keep patients out of institutions and in their homes and in communities.
[12:12] The need for home health care does not disappear when funding is suspended,
[12:20] and California patients are terrified of losing care at home and being forced into institutions.
[12:28] CMS has also threatened my state, New York.
[12:31] When it began investigating New York's program,
[12:35] it touted clumsy and entirely inaccurate math,
[12:38] which ultimately overstated the number of New Yorkers receiving home health care services by nearly 11 times.
[12:47] Even though CMS admitted its error,
[12:50] the Trump administration has not let up on its threat to rob New Yorkers of Medicaid for their health care.
[12:57] We have also heard that the way CMS treats state officials in some blue states has completely changed.
[13:05] CMS seems to be looking for reasons to cut funding to certain states rather than ways to preserve it.
[13:14] Administrator Oz and Vice President Vance have held numerous press conferences
[13:19] to announce hastily determined funding cuts that harm patient access to health care.
[13:28] They have clearly prioritized headlines over health care and partisanship over people.
[13:33] The administration has repeatedly treated blue states as enemies rather than partners.
[13:40] HHS Inspector General March Bell has also joined this campaign against blue states
[13:46] by decertifying Hawaii's Medicaid Fraud Control Unit,
[13:51] cutting $3 million for the entity that is responsible for finding and prosecuting Medicaid fraud and patient abuse or neglect.
[14:00] This is particularly ironic as just the other day,
[14:04] the Department of Justice touted numerous arrests and charges for health care fraud
[14:08] and buried in the DOJ press release is a shout out to the Medicaid Fraud Control Unit of Hawaii
[14:16] as one of the many agencies responsible for prosecuting the cases in the crackdown.
[14:22] One day, they're being denied recertification.
[14:27] The next day, they're part of a major operation that the administration wants all the credit for.
[14:33] Which is it?
[14:35] The answer is that this administration will do anything to cover up for the massive Republican cuts to health care.
[14:43] Enrollment in Medicaid and the Affordable Care Act are dropping precipitously.
[14:47] More than 5 million people just over the past year.
[14:51] CMS and states should work together to address fraud, just as they always have.
[14:58] Getting actual fraud out of the programs and holds actual fraudsters accountable.
[15:04] But wagging a politically motivated assault against, wait, excuse me,
[15:10] waging a politically motivated assault against the sick, the disabled, the blue states,
[15:16] and taking health care away from millions of Americans is not fighting fraud.
[15:20] That's just using fraud as a convenient excuse to carry out the president's harmful agenda
[15:27] with the most vulnerable individuals in our country paying the price.
[15:32] With that, Mr. Chairman, I yield back.
[15:36] Thank you.
[15:36] The chair now recognizes the chairman of the full committee, Mr. Guthrie, for five minutes for an opening statement.
[15:41] Thank you, Mr. Chairman, and I thank you for holding this important hearing.
[15:45] I want to thank all of our witnesses for being here.
[15:47] I know some came in challenging situations, and we really appreciate you being here today.
[15:53] This hearing is about accountability and what all of us can do moving forward
[15:56] to strengthen the Medicaid program integrity.
[15:59] We have a duty to do everything possible to protect the Medicaid program for fraud
[16:05] and preserve it from those who need it most.
[16:08] Each state administers its Medicaid program and is responsible for making sure that fraud prevention
[16:14] and enforcement mechanisms are effective.
[16:17] Unfortunately, this is not always the case.
[16:20] Fraud is not a victimless crime.
[16:23] Not only does it squander taxpayer dollars, but it harms vulnerable patients.
[16:27] Fraudsters are blatantly lining their pockets with taxpayer dollars, often at the expense of the elderly,
[16:34] the disabled, and young patients that are receiving substandard or no medical care.
[16:40] Americans are tired of seeing their hard-earned tax money end up in the hands of criminals.
[16:45] So we can't deny this is happening.
[16:47] It's amazing that it just seems like this is happening.
[16:50] We have a California man, Paul Randall, who pleaded guilty to $270 million in Medicaid fraud.
[16:57] So instead of going to help the most vulnerable and the disabled, where did the money go?
[17:03] He bought luxury cars, rare sports memorabilia, including Mickey Mantle rookie baseball cards,
[17:08] and game-worn sneakers by Kobe Bryant.
[17:10] These are facts.
[17:11] This isn't something that's just that came from this administration.
[17:15] These are facts in law.
[17:16] Similarly, in Ohio, law enforcement recently seized 14 luxury vehicles
[17:21] owned by defendants in a $30 million Medicaid behavioral health case fraud.
[17:28] Just this week, the Department of Justice announced in 2026 a National Health Care Fraud Takedown,
[17:35] which charged 455 defendants with over $6.5 billion in health care fraud.
[17:44] This takedown was a collaborative effort between federal, state, and international partners,
[17:48] including fraud schemes in Medicare and Medicaid.
[17:52] This is another example of how big this problem is.
[17:54] Through more rigorous oversight and enforcement, we can stop these brazen criminal schemes
[18:00] and make the Medicaid program stronger and ensure its stability for the future.
[18:05] So my friend from New York commented on and brought up that the administration just ceased payments
[18:10] and said because you have fraud, you're ceasing payments on all these other programs.
[18:15] Well, let me just say what happened with that.
[18:16] We had over 400 home health providers, so we do want them out of the nursing homes
[18:24] and in their home, 400, over 400 home health care providers providing services in L.A. County.
[18:33] They knew there was rampant fraud, and they couldn't figure out which ones were legit, which weren't.
[18:37] So let's just suspend payments.
[18:39] So if you performed the service, your payment was suspended.
[18:43] If you were cheating, your payment was suspended.
[18:46] Those who 12 companies out of over 400 called and said,
[18:51] where's the money for what we served?
[18:54] 12 legitimate companies out of over 400 in L.A. County.
[18:59] So it's not the administration that was just represented here saying that we're just going to hold,
[19:03] we're going to hold blue states, we're going to punish blue states because they're blue states.
[19:09] What is this administration making the decision that we have rampant fraud,
[19:13] it's ripping off the taxpayers, it's cheating the most vulnerable,
[19:18] some who are in the audience today, the elderly, the disabled,
[19:21] and those who need Medicare and Medicaid the most.
[19:25] And so they're using the tools available.
[19:28] And I will tell you, the 12 companies who legitimately performed those services did get paid,
[19:36] and the other 400 who were cheating never got their money because they didn't do the services.
[19:42] And so I will defend that.
[19:44] I think your taxpayer dollars, the most vulnerables need to be defended as well.
[19:50] I will defend that.
[19:50] And we look forward today to kind of frame this debate to understand what has happened,
[19:56] how we're going to deal with it,
[19:57] and how we make sure that the American people who are generous with their tax dollars,
[20:02] as we had some debates on Medicaid, talked to a lot of people about Medicaid,
[20:05] the American people want this program to work.
[20:07] They want the most vulnerable to be taken care of.
[20:09] But they also want to know that people care about their money as well.
[20:14] And so that's what this hearing's about.
[20:16] That's what we're going to fight for on our side of the aisle.
[20:18] If you're cheating this system, we're going to come after you.
[20:22] And we're going to make sure if you're in the most vulnerable, you're going to be taken care of.
[20:25] And that's our task.
[20:26] And I will yield back.
[20:27] The gentleman yields.
[20:30] The chair now recognizes the ranking member of the full committee, Mr. Pallone,
[20:34] for five minutes for an opening statement.
[20:36] Thank you, Mr. Chairman.
[20:37] Nearly a year ago, Republicans passed their big, ugly bill
[20:40] that included the largest health care cuts in American history.
[20:44] Republicans cut health care by a trillion dollars,
[20:46] which is expected to rip health care away from 15 million Americans.
[20:51] According to a recent study,
[20:52] 5 million Americans have already lost their health insurance as a result of these cuts.
[20:56] And unfortunately, this is just the beginning.
[20:59] During the markup of the big, ugly bill,
[21:00] committee Republicans repeatedly insisted that the cuts wouldn't hurt patients
[21:04] and would only affect waste, fraud, and abuse in the program.
[21:07] But that has proven to be completely false.
[21:10] And they knew that.
[21:11] You cannot cut health care by a trillion dollars
[21:13] and not impact millions of people's health care.
[21:16] Earlier this month, the Trump administration released a rule
[21:18] showing just how burdensome and cruel the new requirements
[21:22] to receive care through Medicaid would be.
[21:24] That rule includes a provision that those receiving ongoing treatment for cancer
[21:28] could lose their Medicaid coverage
[21:30] if they don't jump through all the hoops and red tape that Republicans put in their way.
[21:35] Even cancer patients are under attack by Republican cuts to their health care.
[21:39] The Republicans' big, ugly bill was never going to strengthen Medicaid as they claimed.
[21:43] It was just another step in the Republican campaign to dismantle it.
[21:47] And now, as Republicans try to figure out a way to pay for President Trump's reckless war of choice with Iran
[21:53] through another partisan reconciliation bill,
[21:56] they're reportedly considering even more cuts to Medicaid.
[21:59] More than 70 million Americans who are disabled or chronically ill,
[22:03] elderly or children rely on Medicaid for their health care.
[22:06] The Trump administration and Republicans in Congress continue to find ways to endanger or take away that care.
[22:12] They've decided that if they simply say they're eliminating fraud and Medicaid,
[22:16] then they can get away with eliminating Medicaid.
[22:18] Well, they're wrong.
[22:19] We're not standing for that.
[22:20] The attacks on health care don't stop with the big, ugly bill.
[22:23] Department of Justice just ripped up decades' worth of guidance and precedent
[22:27] that helped keep those with disabilities out of institutions.
[22:31] And the Centers for Medicare and Medicaid Services
[22:33] has selectively abandoned its practice of working in partnership with states
[22:37] to administer the Medicaid program.
[22:40] It's becoming increasingly clear that under Dr. Oz,
[22:43] CMS does not intend to work with states in good faith,
[22:45] particularly states that do not vote or did not vote for President Trump.
[22:50] In California, for example, CMS has deferred $1.3.4 billion in quarterly payments to the state,
[22:56] mostly for home and community-based services,
[22:59] solely based on how quickly the program has grown.
[23:02] If the goal was finding fraud,
[23:03] CMS would identify specific concerning charges and work with the state to resolve them.
[23:08] It would not threaten to defer payments to all in-home supportive services for an entire quarter
[23:13] and then have the vice president hold a celebratory press conference.
[23:17] CMS continues to hold hostage funding to Minnesota,
[23:21] repeatedly making demands of that state with short deadlines,
[23:24] only to move the goalposts when the state meets them.
[23:27] And CMS sent a letter to New York making outlandish allegations
[23:30] about that state's Medicaid program,
[23:32] accompanied by a bombastic social media post from Dr. Oz,
[23:36] claiming that, I quote,
[23:37] nearly three-fourths of the state's 6.8 million Medicaid enrollees received personal care services.
[23:43] But Dr. Oz and CMS had to walk back those claims
[23:46] after it was pointed out that they had committed obvious errors in math
[23:50] that grossly inflated the number of enrollees receiving those services.
[23:54] Now, I'd say if Republicans are really interested in looking into waste, fraud, and abuse,
[23:58] they should look no further than the actions of the Trump administration and the president.
[24:02] I mean, talk about rip-off.
[24:06] The American taxpayers are ripped off every day by Trump's policies
[24:09] and personal, you know, effort to try to make a profit for him and his family.
[24:14] Why don't you go after them?
[24:15] Why don't you go after the administration?
[24:17] But it's outrageous to watch the Trump administration
[24:20] going after state Medicaid programs
[24:22] while it's engaged in reckless war of choice
[24:24] that is costing the American people $132 billion,
[24:28] tanking the economy, and fueling inflation
[24:30] that the president says he loves.
[24:33] He loves inflation.
[24:34] Republicans also had no problem supporting a $1.8 billion slush fund
[24:38] to reward Trump's friends and insurrectionists
[24:41] who assaulted police officers on January 6th.
[24:45] You think that's not a waste of money?
[24:46] Huge waste of money.
[24:48] The combination of the Republicans' big, ugly bill
[24:50] and the politically motivated cuts by CMS
[24:52] put states in an impossible situation,
[24:55] and patients are already paying the price.
[24:57] Playing politics with Americans' health care is cruel and dangerous.
[25:01] Unfortunately, that is what we're repeatedly seeing
[25:03] from Republicans here in Washington.
[25:05] With that, Mr. Chairman, I yield back the balance of my time.
[25:09] The gentleman yields.
[25:10] That concludes the members' opening statements.
[25:12] The chair would like to remind members
[25:14] that pursuant to the committee rolls,
[25:16] all members' written opening statements
[25:18] will be made part of the record.
[25:20] We want to again thank our witnesses for being here today,
[25:23] taking time to testify before the subcommittee.
[25:26] You will have the opportunity to give an opening statement,
[25:29] followed by a round of questions from members.
[25:31] Today's witnesses are Mr. John Connolly,
[25:35] Temporary Commissioner and State Medicaid Director,
[25:38] Minnesota Department of Human Services.
[25:40] Mr. Tyler Sadwith, State Medicaid Director
[25:43] for the California Department of Health Care Services.
[25:47] Mr. Amir Busiri, State Medicaid Director
[25:49] of New York State Department of Health.
[25:52] And Mr. Scott Partika,
[25:54] Director of Ohio Department of Medicaid.
[25:56] We appreciate all of you being here today,
[25:58] and I look forward to hearing from each of you.
[26:00] You are aware that the committee
[26:03] is holding an oversight hearing,
[26:04] and when doing so, has the practice
[26:06] of taking the testimony under oath.
[26:09] Do you have an objection to testifying under oath?
[26:13] Seeing no objection, we will proceed.
[26:15] The chair advises that you are entitled
[26:17] to be advised by counsel pursuant to House rolls.
[26:20] Do you desire to be advised by counsel
[26:22] during your testimony today?
[26:25] Seeing none, please rise.
[26:29] Please raise your right hand.
[26:31] Do you promise to tell the truth,
[26:32] the whole truth, and nothing but the truth,
[26:35] so help you God.
[26:38] Seeing the witnesses answered all in the affirmative,
[26:41] you are now sworn in and under oath,
[26:42] subject to the penalty set forth
[26:44] in Title 18, Section 1001 of the United States Code.
[26:49] With that, I will now recognize, please be seated.
[26:52] With that, I will now recognize Mr. John Connolly
[26:54] for five minutes to give your opening statement.
[26:59] Thank you, Chairman Joyce,
[27:00] Ranking Member Clark,
[27:01] and members of the subcommittee.
[27:03] Thank you for the opportunity to be here today,
[27:05] first of all, and for your continued focus
[27:07] on the important issue of Medicaid integrity.
[27:10] The programs we administer
[27:11] at Minnesota's Department of Human Services
[27:13] are essential to the health, stability,
[27:15] and economic security of communities across Minnesota.
[27:18] They help children, families, seniors,
[27:20] and people with disabilities
[27:21] access healthcare and other essential services every day.
[27:26] These programs are lifelines,
[27:28] relied upon by over a million Minnesotans
[27:30] in communities large and small.
[27:32] As is the case with government-funded programs
[27:34] throughout the country, and in fact,
[27:36] across all healthcare payers,
[27:38] including private insurance,
[27:40] bad actors have tried to take advantage
[27:41] of our well-intended services.
[27:43] But let me be clear.
[27:45] The Minnesota Department of Human Services
[27:47] and the Minnesota government
[27:48] have a zero-tolerance policy
[27:50] for any fraud within our government programs.
[27:53] We take attempts to undermine
[27:54] the integrity of these programs very seriously.
[27:58] We are taking aggressive measures
[27:59] to secure our Medicaid programs,
[28:01] and here are just a few recent examples.
[28:03] Minnesota DHS has conducted over 4,000 investigations
[28:07] and identified more than 50 million
[28:09] in recoveries since 2020,
[28:12] resulting in over 1,150 cases
[28:15] referred to law enforcement, state and federal.
[28:18] Last year, we hired a new inspector general
[28:19] with a decade-long record
[28:21] of prosecuting Medicaid fraud,
[28:22] and we have also increased his staff
[28:24] to enhance oversight and accountability.
[28:26] We have expanded our prepayment review protocols
[28:29] to grow our capability to block payments
[28:31] to fraudulent providers on the front end.
[28:33] Rather than paying them out
[28:35] and trying to recover those funds later.
[28:37] We have aggressively moved to stop payments
[28:39] to providers upon credible evidence of fraud.
[28:43] We designated 14 Medicaid benefits as high-risk,
[28:46] determining that these benefits
[28:48] warranted heightened levels of scrutiny
[28:49] and controls under Medicaid's regulatory framework.
[28:53] Ultimately, we took decisive action
[28:55] to terminate one of those benefits
[28:56] and to impose licensing for service providers in another.
[28:59] We recently completed a five-month comprehensive review
[29:03] of almost 5,600 high-risk Medicaid providers
[29:06] to ensure they meet rigorous eligibility
[29:09] and compliance standards.
[29:11] In appropriate cases,
[29:12] we issued disenrollment notices and stopped payments.
[29:15] We've been doing this work
[29:16] since long before the recent headlines,
[29:18] and we will continue doing it every day.
[29:21] There is no finish line
[29:22] when it comes to protecting the integrity of our programs.
[29:25] Importantly, however,
[29:27] our work is always done with beneficiaries
[29:29] and the broader public in mind.
[29:31] We strive to enhance program integrity
[29:33] while also providing access to care
[29:34] and continuity of service.
[29:36] So, for example,
[29:37] when we disenroll providers,
[29:39] we work closely with counties
[29:40] and in some cases reach out directly
[29:42] to affected Minnesotans
[29:43] to help beneficiaries connect
[29:45] with alternative providers and resources.
[29:47] In pursuing these dual objectives
[29:49] of program integrity
[29:50] and responsible delivery of services,
[29:52] we welcome opportunities for dialogue with Congress,
[29:55] the Centers for Medicare and Medicaid Services,
[29:57] and our fellow states.
[29:58] We all have valuable lessons
[30:00] to learn from each other.
[30:02] We all know that our decisions,
[30:03] as well as those of our federal and state partners,
[30:06] have real-world impacts.
[30:08] Medicaid in Minnesota
[30:09] serves approximately 1.16 million people.
[30:12] Again, children, families, seniors,
[30:15] people with disabilities,
[30:16] those with serious mental health needs,
[30:18] and others who depend on care
[30:19] to remain safe and stable
[30:20] in their homes and communities.
[30:23] Moreover, Medicaid is a foundation
[30:24] for our entire healthcare delivery system,
[30:27] including hospitals and nursing facilities,
[30:29] and major funding losses
[30:30] threaten to destabilize care
[30:32] for all Minnesotans.
[30:34] Recent federal deferrals
[30:35] of Medicaid payments to Minnesota
[30:36] have put our residents at severe risk.
[30:39] This is not an accounting dispute
[30:40] on a spreadsheet.
[30:41] These decisions affect Minnesotans
[30:43] with significant needs,
[30:44] people for whom a missed appointment,
[30:46] a gap in treatment,
[30:48] or an interrupted support service
[30:49] can quickly become a crisis.
[30:51] This is not an either-or decision.
[30:53] We can protect program integrity
[30:55] while still operating
[30:56] these programs effectively.
[30:57] We can root out fraud, waste, and abuse
[31:00] while still caring for those in need.
[31:02] And we can protect taxpayer dollars
[31:04] while simultaneously directing them
[31:06] to their intended beneficiaries.
[31:08] It is our job
[31:09] that we share with our federal partners.
[31:11] I believe strongly in public service
[31:13] and am proud of the work
[31:14] Minnesota DHS has done
[31:16] to strengthen program integrity,
[31:18] combat fraud,
[31:18] and ensure that we continue
[31:20] to secure the federal funding
[31:21] that is crucial to our programs
[31:22] and to Minnesotans.
[31:24] I welcome and encourage
[31:25] continued dialogue with you all
[31:27] as we continue these efforts.
[31:29] Thank you again for the opportunity
[31:30] to share the work we're doing in Minnesota
[31:31] to protect Medicaid program integrity.
[31:34] I look forward to your questions.
[31:37] Thank you.
[31:37] The chair now recognizes Mr. Sadwith
[31:39] for five minutes
[31:40] for an opening statement.
[31:43] Chairman Joyce,
[31:44] Ranking Member Clark,
[31:45] and members of the subcommittee,
[31:46] thank you for the opportunity
[31:47] to testify.
[31:49] My name is Tyler Sadwith,
[31:50] and I am the Medicaid Director
[31:51] for California,
[31:52] a position in the California Department
[31:54] of Health Care Services.
[31:55] I want to be clear from the start.
[31:58] We take program integrity seriously
[32:00] and work hard every day
[32:01] to protect California's Medicaid program
[32:03] from fraud
[32:04] so taxpayer dollars
[32:05] can go to health care services
[32:07] for eligible patients who need them.
[32:10] I would like to touch on three areas.
[32:12] First, I want to highlight California's program
[32:14] and the people we serve.
[32:16] Second, I'd like to demonstrate
[32:18] our unwavering commitment
[32:19] to combating fraud, waste, and abuse.
[32:22] Finally, I want to emphasize
[32:23] our valuable partnership
[32:25] with the federal government
[32:26] and make very clear
[32:27] our ongoing commitment
[32:29] to collaborating
[32:30] with our federal partners
[32:31] at CMS,
[32:32] the Centers for Medicare
[32:32] and Medicaid Services.
[32:36] Medi-Cal is California's
[32:37] Medicaid program.
[32:38] It provides health care services
[32:39] to approximately 14 million
[32:41] vulnerable Americans,
[32:43] including pregnant women,
[32:44] seniors, children,
[32:45] and people with disabilities.
[32:48] California is the country's
[32:49] most populous state.
[32:50] It is the fourth largest economy
[32:51] in the world.
[32:52] This means we support
[32:54] more health care services
[32:55] for more vulnerable individuals
[32:57] than any other state
[32:58] Medicaid program in the country.
[33:00] This is a responsibility
[33:01] we take seriously,
[33:03] and it is a vital part
[33:04] of our mission
[33:04] to protect this program.
[33:06] California is wholly committed
[33:08] to combating fraud,
[33:09] safeguarding taxpayer dollars,
[33:11] and holding bad actors accountable.
[33:13] To meet these commitments,
[33:14] the department prioritizes
[33:16] program integrity
[33:16] at all stages,
[33:18] from provider screening
[33:19] and eligibility determinations,
[33:20] to claims processing,
[33:22] to back-end analysis
[33:23] and investigations.
[33:25] Approximately 20% of staff
[33:27] are dedicated exclusively
[33:28] to program integrity.
[33:30] We have strong policies
[33:31] and protocols that are designed
[33:33] to prevent, identify,
[33:34] and block fraud, waste, and abuse.
[33:36] A comprehensive oversight strategy
[33:39] includes robust provider vetting
[33:41] that exceeds federal standards,
[33:43] provider suspensions,
[33:44] including approximately 5,000
[33:46] over the past five years,
[33:48] and secured fraud recovery
[33:49] totaling more than $1 billion
[33:51] over the past five years.
[33:53] California is one of only
[33:54] two states with a Medicaid agency
[33:57] that employs armed,
[33:59] sworn peace officers
[34:00] with the legal authority
[34:01] to execute search and seizure warrants.
[34:04] Our teams of auditors,
[34:05] investigators, clinicians,
[34:06] and data scientists
[34:07] conduct top-to-bottom reviews
[34:09] of providers.
[34:10] Our strong partnerships
[34:11] with district attorneys,
[34:13] Medicaid fraud-controlled units,
[34:14] and federal law enforcement
[34:15] and investigators
[34:16] are critical to our success.
[34:18] But we must remain vigilant
[34:20] because we know bad actors
[34:22] seek to exploit Medicaid,
[34:24] Medicare,
[34:24] and private health insurance.
[34:26] That is why we continue
[34:27] to strengthen our program
[34:28] in higher-risk areas,
[34:30] such as hospice care.
[34:31] We are implementing new safeguards
[34:33] to ensure appropriate use of services,
[34:35] such as applied behavioral analysis
[34:36] and transportation.
[34:38] We're proud of our program,
[34:39] but I want to emphasize
[34:41] the importance our partnership
[34:42] with CMS plays
[34:44] in ensuring Medi-Cal operates
[34:46] with accountability,
[34:47] transparency,
[34:48] and in compliance
[34:49] with federal requirements.
[34:51] We value that partnership
[34:52] and our shared commitment
[34:54] to protecting taxpayer dollars
[34:56] and maintaining public confidence
[34:57] in Medicaid.
[34:59] A productive relationship
[35:00] with CMS
[35:00] is a key ingredient
[35:01] for continued success.
[35:04] And CMS recognizes California
[35:06] as a national program integrity leader.
[35:09] Across bipartisan administrations,
[35:11] CMS's Medicaid Integrity Institute
[35:13] and the National Association
[35:15] for Medicaid Program Integrity
[35:16] have highlighted
[35:17] our advanced data analytics
[35:19] and investigative strategies.
[35:21] California's program integrity leader
[35:22] recently served
[35:23] on the executive board
[35:24] of the Healthcare Fraud Prevention Partnership,
[35:27] a CMS convened body
[35:29] working across public
[35:30] and private sector
[35:31] to fight fraud.
[35:33] We will be most successful
[35:34] in keeping bad actors
[35:35] out of the program
[35:36] if we continue working closely
[35:38] with CMS
[35:39] and other federal partners.
[35:41] I know this from my own experience
[35:42] at CMS
[35:43] where I served seven years
[35:44] across bipartisan lines.
[35:48] The vast majority
[35:49] of Medi-Cal providers
[35:50] follow the rules.
[35:52] Rooting out unscrupulous providers
[35:53] is critical
[35:54] to safeguarding taxpayer dollars
[35:56] and ensuring Medi-Cal
[35:58] can fulfill its mission
[35:59] to serve the children,
[36:01] pregnant women,
[36:02] and other vulnerable Californians
[36:04] who rely on it.
[36:05] I assure you,
[36:06] California is committed
[36:07] to this important work
[36:08] and unwavering
[36:09] in our efforts
[36:10] to combat fraud.
[36:11] Thank you
[36:12] and I look forward
[36:13] to your questions.
[36:15] Thank you.
[36:15] The chair will now recognize
[36:17] Mr. Basiri
[36:17] for five minutes
[36:19] to give an opening statement.
[36:22] Chairman Guthrie,
[36:24] Ranking Member Pallone,
[36:25] Subcommittee Chairman Joyce,
[36:28] Ranking Member Clark,
[36:30] and members of the subcommittee,
[36:32] thank you for the opportunity
[36:33] to testify today
[36:34] regarding New York,
[36:36] New York's Medicaid program,
[36:37] and our efforts
[36:38] to combat
[36:39] Broadway Sin Abuse.
[36:41] My name is Amir Basiri.
[36:43] I'm Deputy Commissioner
[36:44] and the Medicaid Director
[36:46] at the Office of Health Insurance Programs
[36:48] at the Department,
[36:49] the New York State Department of Health.
[36:52] I've devoted my career
[36:53] in public service
[36:54] to helping ensure
[36:55] that government programs
[36:57] are effective,
[36:58] accountable,
[36:58] and worthy of the trust
[37:00] that the taxpayers
[37:01] put in place in them.
[37:04] I entered this role
[37:04] with a clear responsibility
[37:06] to do what is in the best interest
[37:08] of New York's Medicaid program,
[37:11] including the safeguarding
[37:12] of taxpayer resources,
[37:14] with strong oversight
[37:16] and program integrity
[37:17] so that services
[37:18] are maintained
[37:20] for those who need them the most.
[37:23] New York's Medicaid program
[37:24] is one of the largest
[37:24] in the country,
[37:26] serving more than 6.4 million residents,
[37:30] including over 2 million children,
[37:33] approximately 100,000 pregnant women,
[37:36] and 1.5 million age-blind
[37:38] and disabled residents.
[37:39] Given the magnitude
[37:42] and overall scope
[37:43] of our program,
[37:45] we work every day
[37:46] with state and federal partners,
[37:48] law enforcement,
[37:49] and oversight entities
[37:50] to prevent, detect,
[37:52] and address broad waste and abuse.
[37:55] We also engage regularly
[37:57] with the Center for Medicare
[37:59] and Medicaid Services
[37:59] on program integrity matters,
[38:01] and we sincerely value
[38:04] that partnership
[38:05] as a critical component
[38:06] of our ability
[38:07] to strengthen program integrity efforts.
[38:11] The state recognizes
[38:12] the importance of technology
[38:13] and has made
[38:14] a considerable number
[38:14] of investments
[38:15] in modernizing key technology
[38:18] to both support
[38:19] the consumer
[38:20] and provider experience
[38:22] as well as improving
[38:24] data interoperability
[38:25] and accountability
[38:26] across the delivery system.
[38:30] New York's approach
[38:31] to program integrity
[38:32] relies on multiple state agencies
[38:34] working in close coordination.
[38:37] This provides complementary points
[38:38] of accountability
[38:39] and redundancy
[38:40] in responsibilities
[38:42] to ensure
[38:43] no single point of failure.
[38:44] this structure
[38:46] creates several layers
[38:48] of accountability,
[38:49] including provider monitoring
[38:51] and screening
[38:52] to audits, investigations,
[38:54] and coordinated enforcement action.
[38:57] This approach
[38:58] has produced measurable results.
[39:01] The state continuously
[39:03] enhances its efforts
[39:04] to prevent
[39:05] and detect
[39:05] Broadway sin abuse,
[39:07] and in 2024,
[39:09] the Office of the Medicaid
[39:09] Inspector General
[39:10] completed more than 2,500 audits
[39:14] and investigations,
[39:16] referred over 450 matters
[39:19] for criminal prosecution,
[39:20] and generated approximately
[39:21] $4 billion in recoveries.
[39:24] These outcomes reflect
[39:27] years of sustained work
[39:28] across agencies
[39:29] to identify improper activity,
[39:33] recover funds,
[39:33] and hold bad actors accountable.
[39:36] We are proud
[39:37] of these results,
[39:39] but we also recognize
[39:40] that a program
[39:41] of this size
[39:41] and complexity
[39:42] requires constant vigilance
[39:44] and continuous improvement.
[39:47] Under Governor Hochul's leadership,
[39:49] New York has pioneered
[39:50] a myriad of reforms
[39:52] in high-risk areas
[39:53] to safeguard taxpayer resources.
[39:57] This is most evidenced
[39:58] by the state's right-sizing
[39:59] of the Consumer-Directed
[40:01] Personal Assistance Program,
[40:03] a program that allows
[40:04] Medicaid members
[40:05] to hire their own caregivers
[40:07] by transitioning
[40:09] from a system
[40:10] of over 600 fiscal intermediaries
[40:13] to one single statewide
[40:14] fiscal intermediary,
[40:16] thereby reducing
[40:17] administrative costs
[40:18] in the program
[40:19] while establishing
[40:21] a stronger
[40:21] and more consistent
[40:22] overnight mechanism
[40:23] with full accountability.
[40:27] In addition,
[40:27] a result of enhanced screening
[40:28] and oversight
[40:29] of the non-emergency
[40:31] medical transportation program
[40:33] was done
[40:34] through the creation
[40:35] of a statewide
[40:36] transportation program
[40:37] broker.
[40:39] Nearly 800 providers
[40:41] were terminated
[40:42] or rejected
[40:43] from the network
[40:44] as a result
[40:45] of this transition
[40:46] to the broker,
[40:47] mitigating opportunities
[40:49] for improper billing
[40:50] while preserving access
[40:51] to this critical service.
[40:54] I am proud of the work
[40:55] we've done
[40:56] to protect both
[40:57] the integrity
[40:58] of the Medicaid program
[40:59] and the millions
[40:59] of New Yorkers
[41:00] that depend on it.
[41:01] Protecting the integrity
[41:03] of Medicaid
[41:03] requires collaboration,
[41:05] transparency,
[41:06] and a shared commitment
[41:07] to fiscal stewardship
[41:08] of taxpayer dollars.
[41:10] We deeply value
[41:11] our partnership
[41:12] with federal agencies
[41:13] on this effort
[41:14] and I appreciate
[41:15] the opportunity
[41:16] to testify today
[41:18] and prepare to answer
[41:20] the subcommittee's question.
[41:22] Thank you.
[41:23] The chair now recognizes
[41:24] Mr. Partika
[41:25] for five minutes
[41:26] for an opening statement.
[41:36] Apologies.
[41:36] And members of the subcommittee
[41:38] on oversight investigation,
[41:39] my name is Scott Partika
[41:40] and honored to serve
[41:41] as the director
[41:42] of Ohio Medicaid.
[41:43] I represent all
[41:44] of the Ohio Medicaid team
[41:45] who wake up each
[41:46] and every day
[41:46] with a passion
[41:47] to serve those in need,
[41:49] support our providers,
[41:50] especially our direct caregivers,
[41:53] and execute the program
[41:54] at the highest level
[41:55] of program integrity
[41:56] each and every day.
[41:58] Since joining the department
[41:59] in November of 2025,
[42:00] I found myself laser-focused
[42:01] on program integrity
[42:02] to secure this vital program.
[42:04] Addressing fraud, waste,
[42:05] and abuse
[42:06] within Ohio Medicaid program
[42:07] has always been a focus
[42:08] of the DeWine administration.
[42:10] And our work
[42:11] has especially sharpened
[42:12] and expanded in response
[42:13] to recent program trends
[42:14] noticed in Ohio.
[42:16] And our work is far from over.
[42:18] Ohio has implemented
[42:19] a series of system reforms
[42:21] over the last five years
[42:22] to add operational efficiencies
[42:24] through administrative consolidation,
[42:26] new advanced IT infrastructure.
[42:28] And the results of that
[42:29] are growing transparency
[42:30] and additional tools
[42:31] for accountability
[42:32] that are just now
[42:33] beginning to bear fruit.
[42:36] Key program concerns
[42:37] of previous years
[42:38] include payment accuracy,
[42:40] member eligibility,
[42:41] and concurrent enrollment
[42:41] in other states,
[42:43] as well as broader
[42:43] program spending
[42:44] in certain areas.
[42:46] Ohio has taken steps,
[42:47] each concern head-on,
[42:49] including reducing
[42:50] the PERM finding to 2%,
[42:52] adding new supports
[42:53] for county caseworkers
[42:54] to increase accuracy
[42:55] and efficiency
[42:56] of applications,
[42:57] and increasing data transparency
[42:58] along the way
[42:59] that has helped guide policymaking
[43:01] for the administration
[43:03] and Ohio legislature.
[43:05] Other ongoing initiatives
[43:06] include role and policy updates,
[43:08] enhanced provider screenings,
[43:10] new UM practices,
[43:12] and targeted provider audits.
[43:14] These and other activities
[43:15] have helped us address concerns
[43:16] highlighted by state partners
[43:18] and partners at CMS.
[43:21] When looking at federal initiatives
[43:22] to combat program integrity concerns,
[43:24] it's important to recognize
[43:25] the working families tax cut legislation,
[43:28] which dramatically increased
[43:29] the level of program oversight
[43:30] and elevated program integrity priorities
[43:33] in state Medicaid programs,
[43:35] including addressing
[43:36] concurrent enrollment across states,
[43:39] ensuring deceased individuals
[43:40] are no longer on the rules,
[43:41] increased emphasis of audits
[43:43] and subsequent corrective action,
[43:45] increased frequency
[43:46] of eligibility determination,
[43:48] mandating community engagement requirements
[43:50] to help facilitate people
[43:51] moving up and off the program.
[43:53] These efforts are helpful
[43:54] and we believe our federal partners
[43:55] can and should continue
[43:57] to improve protection
[43:59] and oversight of state programs.
[44:02] Now to Ohio.
[44:03] Troubling data in home health space
[44:05] was uncovered at Ohio
[44:06] late last year.
[44:07] We began investigating the information
[44:08] in conjunction with Ohio auditor
[44:10] Keith Faber
[44:10] and former Attorney General Dave Yeo
[44:12] shortly thereafter.
[44:14] The result culminated
[44:15] in new actions and initiatives
[44:16] to address areas of weakness,
[44:17] combat the fraudsters' attempt
[44:19] at exploiting these critical programs.
[44:22] In recent weeks,
[44:23] Governor DeWine announced
[44:24] several new initiatives
[44:25] aimed at curbing that trend.
[44:26] A six-month moratorium
[44:27] on new home health providers,
[44:29] increased frequency
[44:30] of provider revalidations,
[44:31] new rules to conduct
[44:32] provider payment suspensions
[44:34] during periods of investigations,
[44:36] and updating Ohio's
[44:37] electronic visit verification rules.
[44:40] Additionally,
[44:40] the Ohio legislature
[44:41] passed Senate Bill 315,
[44:42] which includes a myriad of reforms
[44:44] to the integrity
[44:45] of the Ohio Medicaid program,
[44:47] including increased penalties
[44:48] for fraud violations,
[44:49] expanded oversight
[44:50] of provider ownership structures,
[44:52] enhanced provider enrollment requirements,
[44:54] and expanded use
[44:55] of electronic visit verification.
[44:57] Work to strengthen
[44:58] other high-risk programs
[44:59] is also underway.
[45:00] It is a full press forward
[45:01] to address fraud, waste, and abuse
[45:03] through a thorough policy review
[45:05] across the agency.
[45:07] Through these efforts,
[45:08] we have identified certain areas,
[45:09] such as Ohio's nursing facility
[45:11] ventilator program,
[45:12] for improvements,
[45:13] private room compliance monitoring,
[45:15] oversight of certain behavioral health services,
[45:17] home health,
[45:19] and skin substitute coverage
[45:20] are just a few
[45:21] where we are making policy updates.
[45:24] Moving forward,
[45:25] one area we believe
[45:25] the federal government
[45:26] and states could partner
[45:27] is through improved data sharing
[45:30] and tracking of provider ownership
[45:31] and affiliation
[45:32] across state lines and programs.
[45:34] As we continue
[45:35] our program integrity work,
[45:36] it is critical
[45:37] that we are able
[45:38] to systematically root out bad actors
[45:40] and not leave the door open
[45:41] for any exploitation
[45:42] of this program.
[45:43] If somebody is taking advantage
[45:45] of our program
[45:46] in Northwest Ohio,
[45:47] I certainly want to ensure
[45:49] our partners
[45:49] across the state lines
[45:50] in Michigan
[45:51] are aware of that as well.
[45:54] The department is committed
[45:55] to ensuring Ohioans
[45:56] receive health care
[45:57] in accordance with the law
[45:58] and rooting out fraud,
[45:59] waste, and abuse
[46:00] to protect this vital
[46:01] and critical program
[46:02] for the people who need it.
[46:05] Chairman Joyce,
[46:05] Vice Chair Balderson,
[46:06] Reiki Member Clark,
[46:07] members of the committee,
[46:08] thank you for having me today.
[46:09] I look forward to your questions
[46:10] and continued work moving forward.
[46:13] Thank you.
[46:13] I thank you all
[46:15] for your testimony.
[46:16] We will now move
[46:17] to questioning.
[46:18] I will begin
[46:19] and recognize myself
[46:20] for five minutes.
[46:24] Director Sadwith,
[46:25] California has
[46:26] a large Medicaid program
[46:28] spending more than
[46:29] $4.7 billion in 2025
[46:32] on home
[46:33] and community-based services alone.
[46:36] Fraud in these services,
[46:37] as you would recognize,
[46:39] is a serious matter.
[46:40] In some cases
[46:41] across the country,
[46:42] patients have died
[46:43] when fraudsters
[46:44] bill Medicaid
[46:45] for services
[46:46] that were needed
[46:48] but never provided.
[46:50] Your office has stated
[46:51] in correspondence
[46:52] with this committee
[46:53] and CMS
[46:53] that California
[46:54] goes beyond
[46:56] federal requirements
[46:57] for providing
[46:58] screening and enrollment.
[47:00] If that is the case,
[47:02] why has your Medicaid agency
[47:04] classified all
[47:05] Medicaid-only providers
[47:07] as limited risk,
[47:09] a classification
[47:10] that comes with
[47:11] less stringent
[47:12] oversight standards?
[47:13] Do all of California's
[47:15] Medicaid providers
[47:16] being considered
[47:18] as limited risk
[47:19] really reflect
[47:20] what you are seeing
[47:21] in these programs?
[47:24] Thank you, Chairman,
[47:25] for the question
[47:26] and thank you again
[47:27] for the opportunity
[47:27] to be here today.
[47:30] Home and community-based services
[47:31] are a vital program
[47:32] in California.
[47:34] We know, for example,
[47:36] that they're cost-effective,
[47:40] reflecting a prudent use
[47:41] of taxpayer dollars,
[47:42] one year of receiving
[47:44] in-home supportive services
[47:46] saves federal and state
[47:47] taxpayer dollars
[47:48] approximately $100,000
[47:50] compared to a stay
[47:51] in a nursing facility.
[47:53] We are absolutely committed
[47:54] to ensuring the integrity
[47:55] of these vital services.
[47:57] But by classifying
[47:58] all Medicaid-only programs
[48:00] as limited risk,
[48:02] are you seeing
[48:03] that all of these programs
[48:04] really show
[48:04] the limited risk
[48:05] as far as fraud goes?
[48:08] Thank you for the question.
[48:10] So the risk classification,
[48:12] categorical risk level
[48:13] classification is one
[48:14] of many tools
[48:15] that we use
[48:16] to assess program risk.
[48:18] Is this adequate?
[48:19] When you paint with one brush
[48:21] all of those
[48:22] as limited risk,
[48:23] which requires less oversight,
[48:26] are you missing fraud?
[48:29] We employ a number
[48:30] of safeguards
[48:30] to prevent bad actors
[48:32] from entering the program.
[48:34] For in-home supportive services
[48:35] specifically,
[48:37] we do conduct fingerprint
[48:38] and criminal background checks,
[48:40] which is one of the features
[48:41] of a high-risk,
[48:43] categorical-level
[48:44] designation.
[48:46] So even though-
[48:46] But is that at this high risk?
[48:48] Well, we're talking
[48:48] about limited risk,
[48:49] which you ascribed
[48:50] to all Medicaid-only providers.
[48:53] Does that catch
[48:54] all the fraudsters,
[48:55] or should this be more
[48:56] of an individualized approach
[48:58] and not painting
[48:59] just with one brush?
[49:00] Is there an opportunity
[49:01] to really weed out the fraud
[49:04] at its beginning stages?
[49:06] I absolutely share your focus.
[49:09] Have you previously designated
[49:10] any Medicaid-only provider types
[49:12] that were classified
[49:14] as moderate or high-risk?
[49:17] To my knowledge,
[49:18] we have not classified
[49:20] any Medicaid-only provider types.
[49:23] We have gone above
[49:24] and beyond historically
[49:26] the federally designated risk risk.
[49:28] In California,
[49:29] are you reassessing
[49:30] any provider risk designations
[49:32] in the state?
[49:34] Thank you.
[49:34] We are actively assessing
[49:36] opportunities to strengthen
[49:38] program integrity
[49:39] in key areas.
[49:40] this includes
[49:41] but is not limited
[49:42] to the categorical
[49:44] risk-level designation.
[49:46] We do have other tools
[49:47] that we use
[49:48] to go after higher-risk areas.
[49:51] We have developed
[49:52] provider risk profilers
[49:54] for services,
[49:55] you know,
[49:56] such as hospice care,
[49:57] such as dental care,
[49:59] and other areas
[50:01] that are on our radar
[50:01] that we use,
[50:03] you know,
[50:03] in conjunction
[50:04] with, you know,
[50:05] comprehensive...
[50:05] Okay, Jill,
[50:06] you brought into
[50:07] this conversation now
[50:08] home health
[50:09] and hospices.
[50:10] Am I correct
[50:11] that California license
[50:12] home health
[50:13] and hospices
[50:14] before they can operate
[50:16] in the state?
[50:18] Thank you for that question.
[50:19] This is a really important issue
[50:21] that I'm happy
[50:22] to talk about.
[50:23] It's really important...
[50:24] Please do.
[50:26] Yeah, the partnership
[50:27] between the state of California
[50:28] and the federal government
[50:29] is paramount
[50:30] to making sure
[50:31] bad actors
[50:32] stay out of the program
[50:33] when it comes to hospice care
[50:35] and home health.
[50:36] Just as context,
[50:38] Medicare,
[50:38] the federal program,
[50:39] is the primary payer
[50:40] for hospice care
[50:42] in California.
[50:43] The state department,
[50:45] California Department
[50:46] of Public Health,
[50:47] my sister state agency,
[50:49] does perform licensure
[50:50] for hospice providers
[50:52] and the state
[50:53] has acted swiftly
[50:54] to root out bad...
[50:55] So before they can operate
[50:56] in California,
[50:57] this is just a simple
[50:58] yes-no.
[50:59] Do you allow
[51:01] this hospice organization
[51:03] to operate
[51:05] with or without
[51:06] without a California license?
[51:08] Is that required
[51:09] before they can operate
[51:11] in California?
[51:12] Yes or no?
[51:14] The California Department
[51:15] of Public Health
[51:15] has imposed
[51:16] a licensure moratorium
[51:17] that was enacted
[51:18] in 2021
[51:19] and just this week
[51:20] implemented new regulations
[51:22] strengthening the standards
[51:24] for licensure
[51:24] for providers
[51:25] to be able to obtain...
[51:26] So prior to just this week,
[51:28] your words,
[51:29] you could operate
[51:30] a hospice
[51:31] in California
[51:32] without a license?
[51:33] Is that what you just
[51:34] said to me?
[51:34] Pardon me,
[51:36] I respectfully disagree
[51:38] with the framing.
[51:39] I'm actually not
[51:40] an expert
[51:41] on that specific...
[51:42] Okay, so let's move on.
[51:44] Director Basiri,
[51:45] personal care
[51:46] and home health aides
[51:47] are the largest
[51:48] and fastest growing
[51:49] job category
[51:49] in New York
[51:50] and according to CMS
[51:51] accounted for
[51:52] more than $44 billion
[51:54] in total payments
[51:56] between 2023
[51:57] and 2025.
[51:59] I understand
[51:59] based on information
[52:00] that New York
[52:01] provided to the committee
[52:02] just yesterday,
[52:04] even though it was requested
[52:05] in March
[52:06] that New York State
[52:07] Department of Health
[52:08] is in the process
[52:09] of designating
[52:10] Waivered Personal Care Services
[52:12] as a high-risk program.
[52:14] Given that CDPAP,
[52:16] which is a self-directed
[52:17] personal care service
[52:18] waiver program,
[52:19] is provided in private homes
[52:22] with minimal oversight,
[52:24] what safeguards currently exist
[52:26] to verify the services
[52:27] are billed actually
[52:28] and delivered?
[52:31] Thank you for the question,
[52:32] Chairman.
[52:33] I'm going to ask you,
[52:33] my time has expired,
[52:34] I'm going to ask you
[52:35] to respond to that
[52:36] in writing.
[52:37] And with that,
[52:38] I will yield
[52:39] to the ranking member
[52:40] for her five minutes
[52:41] of questioning.
[52:42] Thank you very much,
[52:43] Mr. Chairman.
[52:44] Under the partisan leadership
[52:46] of Donald Trump
[52:47] and Dr. Oz,
[52:48] CMS's use of its authority
[52:50] to withhold
[52:50] and defer Medicaid funding
[52:52] for Minnesota
[52:53] and California
[52:54] is extreme
[52:55] and unprecedented.
[52:56] And the CMS threat
[52:58] against New York
[52:59] based on basic math errors
[53:01] are an embarrassment.
[53:03] Under the leadership
[53:04] of Administrator Oz,
[53:06] CMS no longer supports
[53:07] all states
[53:08] in administering
[53:09] their Medicaid programs.
[53:10] Instead,
[53:11] it seems to be looking
[53:12] for ways
[53:13] to undermine
[53:14] these programs.
[53:16] CMS is demanding
[53:17] that states solve problems
[53:18] in their Medicaid programs
[53:19] without defining
[53:20] what the problems are.
[53:22] Or in the case of New York,
[53:24] CMS has based its scrutiny
[53:25] of Medicaid spending
[53:26] on an embarrassing
[53:27] misinterpretation
[53:29] of its own data.
[53:31] Mr. Bassieri,
[53:32] Dr. Oz sent you a letter
[53:33] on March 3rd
[53:34] that stated that
[53:35] nearly three out of
[53:36] every four Medicaid beneficiaries
[53:38] received personal care services
[53:40] from 2023
[53:42] through part of 2025.
[53:45] Dr. Oz posted that letter
[53:47] on social media
[53:47] along with a video
[53:49] threatening New York's
[53:50] Medicaid funding.
[53:52] Mr. Bassieri,
[53:52] was the statement
[53:53] that Dr. Oz made
[53:55] about the number
[53:56] of Medicaid beneficiaries
[53:57] receiving personal care services
[53:59] accurate?
[54:02] Thank you for the question,
[54:03] Reggie and Member Clark.
[54:05] That information
[54:07] that was reported
[54:07] was inaccurate.
[54:10] We did confirm
[54:11] and state that
[54:12] and the administration
[54:13] confirmed.
[54:15] There are 450,000
[54:18] New Yorkers
[54:19] that receive
[54:20] some form
[54:21] of personal care services
[54:23] including consumer directed
[54:24] and licensed home care.
[54:26] It is not the 4 million
[54:28] that was referenced.
[54:29] It's a little under 5%.
[54:31] Mr. Bassieri,
[54:33] do you know
[54:34] about how far off
[54:36] Dr. Oz was
[54:37] from the actual number?
[54:38] I think you just stated it
[54:39] a minute ago.
[54:41] Thank you for the follow-up.
[54:44] The discrepancy
[54:45] was between
[54:46] 4 million
[54:47] and 450,000.
[54:49] Yikes.
[54:50] This is not a minor
[54:52] rounding error.
[54:53] This is a fundamental
[54:54] misunderstanding
[54:55] of Medicaid programs
[54:56] and basic math.
[54:57] And it is shameful
[55:00] to be that far off
[55:02] and think that
[55:03] it is New York
[55:04] that has the problem.
[55:06] Setting aside
[55:07] the egregious
[55:08] misrepresentation
[55:10] of the facts,
[55:11] Mr. Bassieri,
[55:12] were you aware
[55:13] that one of the footnotes
[55:15] in the same letter
[55:15] shows that CMS
[55:17] apparently used
[55:18] ChatGPT
[55:19] to find an article
[55:20] on CMS's own data?
[55:24] Thank you for the question.
[55:25] I had not been aware of that.
[55:27] Yeah, I think this is relevant
[55:28] because it demonstrates
[55:29] that CMS is not taking
[55:31] the time
[55:31] to assess its data
[55:33] to identify
[55:34] specific program
[55:35] integrity concerns.
[55:36] And it's clear
[55:37] that President Trump
[55:39] and Dr. Oz
[55:40] decided to go
[55:41] after New York
[55:42] and then tried
[55:42] to manufacture
[55:44] the basis
[55:45] for doing it.
[55:46] Mr. Sandwith,
[55:48] in response
[55:49] to CMS's
[55:50] determination
[55:51] in May
[55:51] to defer
[55:52] $1.34 billion
[55:54] from your program,
[55:55] you said
[55:55] CMS has used
[55:57] what was once
[55:58] a routine payment
[55:59] and reconciliation
[55:59] process with states
[56:01] to undermine
[56:02] exactly what
[56:02] federal HCBS policy
[56:05] has long sought
[56:06] to achieve,
[56:07] helping more people
[56:08] remain safely at home
[56:09] rather than enter
[56:10] institutions
[56:10] for long-term care.
[56:12] Can you explain
[56:13] how the May referral
[56:14] announced by CMS
[56:16] differs,
[56:18] excuse me,
[56:19] differs from prior deferrals?
[56:23] Thank you,
[56:23] Ranking Member.
[56:24] I'd be happy to.
[56:26] First of all,
[56:27] we value transparency
[56:28] and we do value
[56:29] the review process
[56:30] with CMS.
[56:31] Some of the deferrals
[56:33] in that deferral
[56:33] are actually a result
[56:35] of California
[56:35] proactively reaching out
[56:37] to CMS
[56:38] and disclosing concerns
[56:40] and issues
[56:40] we had identified
[56:41] in seeking partnership
[56:42] with CMS
[56:43] to ensure federal
[56:44] appropriate claiming.
[56:46] However,
[56:46] the $1.1 billion
[56:47] deferral
[56:48] for our in-home
[56:49] supportive services
[56:50] is unprecedented.
[56:53] We began addressing
[56:55] CMS questions
[56:56] questions before the deferral
[56:57] was ever issued.
[56:58] They reviewed intensively
[57:00] and we value
[57:01] that partnership.
[57:02] We explained the growth.
[57:03] We explained that
[57:04] intentional policy choices
[57:06] reflecting long-standing
[57:08] federal policy
[57:09] and federal authorities
[57:11] to expand home
[57:12] and community-based services
[57:13] and keep vulnerable
[57:14] Americans at home
[57:16] saving taxpayer dollars
[57:17] was part of our strategy,
[57:20] part of our policy.
[57:21] We explained what drove
[57:22] the growth
[57:23] and CMS decided
[57:24] to defer
[57:25] the payments
[57:27] and they have not
[57:28] provided any instances
[57:29] of fraud, waste
[57:30] or abuse
[57:31] as part of their review.
[57:34] Does an extended delay
[57:35] in releasing federal funds
[57:37] threaten accessibility
[57:38] of services for patients?
[57:40] We are continuing
[57:41] to monitor
[57:42] the impact
[57:43] on access to patients
[57:44] as a result
[57:45] of this deferral
[57:46] and working steadfastly
[57:47] to continue responding
[57:49] to every question
[57:50] CMS asks us.
[57:51] Very well,
[57:52] Mr. Chairman,
[57:53] I yield back.
[57:54] Thank you, gentlemen.
[57:54] General Lady yields.
[57:57] The chair now recognizes
[57:58] the chairman
[57:58] of the full committee,
[57:59] Mr. Guthrie,
[58:00] for five minutes
[58:00] of questioning.
[58:01] Thank you.
[58:02] So first for Director Basiri,
[58:04] New York has failed
[58:05] to provide certain
[58:05] information response
[58:06] to the committee's letter.
[58:08] For example,
[58:09] you've not provided
[58:09] simple information
[58:10] such as all the state's
[58:11] designated risk levels
[58:12] for Medicaid-only providers,
[58:14] types.
[58:15] Also note that you only
[58:16] provided the basic information
[58:17] that was requested
[58:18] about the frequency
[58:19] of on-site visits
[58:20] and yearly improper payment
[58:21] and recovery efforts
[58:22] the day before.
[58:24] Why have you been unable
[58:24] to provide that information
[58:26] to the committee?
[58:28] Thank you for the question,
[58:29] Chairman.
[58:30] We have been as responsive
[58:32] as we can.
[58:34] We're handling many inquiries
[58:35] from both the committee,
[58:37] the Center for Medicare
[58:38] and Medicaid Services
[58:39] and HHS OIG,
[58:41] but I'm happy
[58:42] to take that back.
[58:43] So we brought this up
[58:44] to you on March 3rd.
[58:45] It's now June 25th.
[58:47] If your agency
[58:48] doesn't have this information
[58:49] readily accessible,
[58:50] that's a problem in itself.
[58:52] But the committee
[58:53] and the American people
[58:53] deserve to have transparency
[58:55] on how New York
[58:56] and all states
[58:56] are operating in their program.
[58:58] And will you commit
[58:59] to providing that information
[59:00] to this committee
[59:01] that we've requested?
[59:03] Thank you for the follow-up.
[59:05] We agree that transparency
[59:06] is paramount.
[59:08] I can't commit to that here,
[59:10] but I'm happy to take that back
[59:11] and get back to you
[59:12] as soon as possible.
[59:12] You can't commit
[59:12] to providing the information
[59:14] I just laid out?
[59:16] I think we've been...
[59:18] I'm happy to take that back
[59:19] and get back to you.
[59:20] Well, thank you.
[59:20] So, Director Satwith,
[59:22] kind of a same committee
[59:25] requested documents,
[59:26] information from your agency
[59:27] on March 3rd,
[59:28] including all audits
[59:29] related to fraud,
[59:31] waste, and abuse
[59:31] in the state's Medicaid programs,
[59:33] including audits
[59:33] completed by third-party
[59:34] contract auditors
[59:36] from January 1st, 2021 to present.
[59:39] I think that's about the time
[59:39] you said the licensing was ceased.
[59:42] I think I said...
[59:42] I might have said in-home.
[59:43] I think it was hospice care
[59:44] when I was referring earlier.
[59:46] Based on the information
[59:47] that has been provided
[59:48] to the committee,
[59:48] we know that California
[59:49] has conducted such audits,
[59:50] but the committee
[59:51] did not receive
[59:52] a single audit document
[59:53] from California
[59:54] until 7 p.m. last night.
[59:57] Do you believe that
[59:58] providing more than 1,300 pages
[1:00:00] of documents
[1:00:01] on the eve of a hearing
[1:00:02] is fair to this committee?
[1:00:05] Thank you, Chairman.
[1:00:06] And I acknowledge the frustration.
[1:00:09] We have been working
[1:00:10] with committee staff
[1:00:11] to produce information
[1:00:13] and address the questions,
[1:00:15] including the list
[1:00:16] of 26,000 audits
[1:00:18] and investigations
[1:00:19] that we have conducted
[1:00:20] over the past five years
[1:00:21] last night.
[1:00:23] We provided some audits
[1:00:26] related to transportation
[1:00:28] and mental health
[1:00:29] that the committee
[1:00:30] had indicated were...
[1:00:32] There are also others
[1:00:33] that we've requested.
[1:00:34] Do you commit to providing
[1:00:35] what we've requested
[1:00:37] to this committee
[1:00:37] in a timely manner?
[1:00:40] Thank you, Chairman.
[1:00:40] There are ongoing
[1:00:42] law enforcement investigations
[1:00:44] that would be impacted
[1:00:47] by those specific audits
[1:00:49] that were requested.
[1:00:50] We're happy to provide
[1:00:51] the appropriate information
[1:00:52] at the appropriate time.
[1:00:54] Let me say,
[1:00:54] it just seems unfair to us
[1:00:56] and to prepare for a hearing
[1:00:57] that you've sent everything
[1:00:58] at 7 p.m. last night.
[1:01:00] It almost seems like
[1:01:00] that was intentional.
[1:01:02] It appears that way.
[1:01:03] So, Temporary Commissioner Connolly,
[1:01:06] the Early Intensive Development
[1:01:07] Behavioral Intervention Program,
[1:01:09] which provides
[1:01:09] autism therapy services
[1:01:11] in Minnesota,
[1:01:11] is currently experiencing
[1:01:12] unprecedented levels of fraud,
[1:01:14] exemplified by a recent fraud
[1:01:16] takedown in Minnesota,
[1:01:17] charged by DOJ
[1:01:18] tolling $46.6 million,
[1:01:20] one of the largest in history.
[1:01:22] In this scheme,
[1:01:23] it is alleged
[1:01:23] that the defendants
[1:01:25] pay kickbacks to parents
[1:01:26] to bring their children
[1:01:27] to autism centers
[1:01:27] where children were diagnosed
[1:01:29] with autism regardless
[1:01:30] of the medical necessity.
[1:01:32] What are you doing
[1:01:32] to restore
[1:01:33] the Early Intensive Development
[1:01:34] and Behavioral Intervention Program
[1:01:36] to provide these services
[1:01:37] to those who it's intended for?
[1:01:40] Thank you, Chairman Guthrie,
[1:01:41] for the question.
[1:01:42] So, we are engaged
[1:01:43] in a number of efforts
[1:01:44] related to the autism services
[1:01:47] benefit in Minnesota
[1:01:47] and certainly significant fraud happened
[1:01:50] and I am not here
[1:01:51] to minimize that.
[1:01:52] However, as the fraud
[1:01:53] became apparent to us
[1:01:54] based on the information
[1:01:55] we were able to collect
[1:01:56] through investigations
[1:01:57] and through data analytics,
[1:01:59] we took a number of actions.
[1:02:01] I think one of the first
[1:02:01] was in October of 2024.
[1:02:04] Our staff did an on-site audit
[1:02:06] of all autism service providers
[1:02:07] in the program
[1:02:08] across the state.
[1:02:10] Later, it was designated
[1:02:11] as a high-risk service,
[1:02:13] so that comes with
[1:02:14] enhanced fingerprint background checks,
[1:02:16] unannounced site visits,
[1:02:17] a more frequent revalidation.
[1:02:19] Those providers
[1:02:20] are also included
[1:02:21] in the revalidation
[1:02:23] of the 5,600 providers
[1:02:24] that I described
[1:02:25] in my opening comments.
[1:02:26] We also implemented,
[1:02:27] pursuant to the direction
[1:02:28] of the legislature,
[1:02:29] a new licensing framework
[1:02:31] for autism service providers.
[1:02:34] That is being implemented now.
[1:02:35] It's being phased in.
[1:02:36] We have a provisional licensure framework
[1:02:38] that providers,
[1:02:40] the vast majority of providers,
[1:02:42] have applied for,
[1:02:43] and then full licensure
[1:02:44] will come into place in 2027.
[1:02:47] Well, thank you.
[1:02:47] My time is running out.
[1:02:48] I just want to say,
[1:02:49] you said significant fraud
[1:02:50] has been committed
[1:02:51] and you're not denying that
[1:02:53] or downplaying that.
[1:02:54] I think that's the word you said,
[1:02:55] which I appreciate that.
[1:02:56] I think hopefully all of you
[1:02:58] would admit to that.
[1:02:59] And my wish is that
[1:03:00] in a bipartisan way,
[1:03:01] all of us on here,
[1:03:02] instead of,
[1:03:03] well, the administration did this
[1:03:04] and fraud and whatever,
[1:03:06] there's significant fraud
[1:03:07] in the programs
[1:03:07] that not just the four of you
[1:03:09] are representing.
[1:03:10] I think if you look across,
[1:03:11] I don't know every,
[1:03:11] I'm not going to say every say
[1:03:12] because I don't know that,
[1:03:13] but I think it's absolutely significant.
[1:03:15] And it just seems like
[1:03:16] this is one thing
[1:03:17] we could all agree
[1:03:18] that we should fight the fraud
[1:03:20] of significant levels.
[1:03:21] You said significant
[1:03:22] is the word that you use.
[1:03:23] And I want to ask you,
[1:03:24] my time's now up,
[1:03:25] but I think this is just something
[1:03:27] that's frustrating
[1:03:27] that we're not,
[1:03:29] this isn't a bipartisan effort
[1:03:30] to root out fraud.
[1:03:31] I'll yield back.
[1:03:33] The gentleman yields.
[1:03:34] The chair now recognizes
[1:03:35] the ranking member of the committee,
[1:03:37] Mr. Pallone,
[1:03:37] for five minutes of questioning.
[1:03:39] Thank you, Mr. Chairman.
[1:03:40] The Republicans' big, ugly bill
[1:03:42] cut health care by a trillion dollars.
[1:03:44] And then the Trump administration
[1:03:45] launched a campaign
[1:03:46] to cut health care
[1:03:47] to blue states even more.
[1:03:49] On February 26th,
[1:03:50] just two days before Trump began
[1:03:52] his reckless war of choice
[1:03:54] with Iran,
[1:03:55] Vice President Vance
[1:03:56] announced a deferral
[1:03:57] of $250 million
[1:03:58] in Medicaid funding
[1:04:00] to Minnesota.
[1:04:00] So I want to ask Dr. Connolly,
[1:04:02] actually I'm going to go
[1:04:02] to each of the three
[1:04:04] state representatives,
[1:04:05] so, you know,
[1:04:06] if you could just respond
[1:04:07] in a minute or so.
[1:04:08] So, Dr. Connolly,
[1:04:10] you've described the deferral
[1:04:11] as a, quote,
[1:04:12] catastrophic funding loss
[1:04:13] for Minnesota
[1:04:14] and the children,
[1:04:15] families,
[1:04:16] and seniors
[1:04:16] that rely on the program.
[1:04:18] So what does
[1:04:19] an unprecedented deferral
[1:04:20] of this size
[1:04:21] mean for Minnesota
[1:04:22] children and families?
[1:04:24] And has CMS
[1:04:24] given you any indication
[1:04:26] of whether these
[1:04:27] deferred payments
[1:04:28] will be released
[1:04:29] or when?
[1:04:31] So the size
[1:04:32] of both the deferrals,
[1:04:33] which are roughly
[1:04:33] $350 million,
[1:04:35] on top of the
[1:04:36] $2 billion roughly
[1:04:37] annual withholding
[1:04:39] associated with CMS's
[1:04:40] compliance action,
[1:04:41] that is a significant
[1:04:43] amount of money
[1:04:43] when the entire program
[1:04:45] is roughly $20 billion
[1:04:46] in entire federal
[1:04:47] and state spend.
[1:04:48] So that is a very large
[1:04:50] sum of money
[1:04:51] that threatens
[1:04:52] the state's ability
[1:04:52] to finance the services
[1:04:54] and benefits
[1:04:55] that are part
[1:04:55] of the program.
[1:04:57] In addition,
[1:04:58] we have a structural
[1:04:59] budget deficit
[1:05:00] in Minnesota.
[1:05:00] We've had that
[1:05:01] for a couple of years now,
[1:05:03] and so we are already
[1:05:04] struggling to maintain
[1:05:06] the services,
[1:05:07] the payment levels
[1:05:07] for providers
[1:05:08] across the state,
[1:05:09] the eligibility levels
[1:05:10] that we have
[1:05:11] in the program.
[1:05:12] So this adds another layer
[1:05:13] of pressure and risk
[1:05:14] to those realities.
[1:05:16] With respect to CMS
[1:05:18] and us working with them,
[1:05:19] we have done everything
[1:05:20] since December 5th
[1:05:21] in the notification
[1:05:22] that they were requiring
[1:05:24] a corrective action plan
[1:05:25] of us that they have asked.
[1:05:27] We've revised it once,
[1:05:29] provided that timely on time,
[1:05:31] and have implemented
[1:05:32] every step and milestone
[1:05:33] in that corrective action plan
[1:05:35] since we submitted it.
[1:05:36] Any indication
[1:05:37] of whether these payments
[1:05:38] will be released or when?
[1:05:39] I'm just trying to move on.
[1:05:41] None yet.
[1:05:42] Representative Pallone,
[1:05:43] thank you.
[1:05:43] I appreciate it.
[1:05:44] I'm just trying
[1:05:44] to get all of you in.
[1:05:46] In California,
[1:05:46] CMS has targeted
[1:05:48] home and community-based
[1:05:49] services, or HCBs.
[1:05:51] Cuts to HCBs mean
[1:05:52] Medicaid recipients
[1:05:53] will end up in institutions
[1:05:55] rather than get care
[1:05:56] in their homes
[1:05:57] or receive no care
[1:05:58] at all, possibly.
[1:05:59] So Mr. Sadwith,
[1:06:00] if HCBs are cut
[1:06:04] and patients are forced
[1:06:05] into institutions,
[1:06:06] what are the consequences
[1:06:07] for patients,
[1:06:08] their families,
[1:06:09] and taxpayers?
[1:06:10] In about a minute,
[1:06:11] if you don't mind.
[1:06:13] Thank you for the question,
[1:06:14] Representative.
[1:06:17] So I'd like to take a minute
[1:06:18] just to talk about
[1:06:19] what these services are
[1:06:21] and who's receiving them,
[1:06:22] to put a human face on them.
[1:06:24] So in-home supportive services
[1:06:26] are provided to some
[1:06:28] of California's
[1:06:28] most vulnerable residents,
[1:06:30] including children
[1:06:30] with disabilities,
[1:06:32] adults with disabilities,
[1:06:33] and seniors
[1:06:34] who cannot live safely
[1:06:35] at home.
[1:06:36] All in-home supportive
[1:06:38] services recipients
[1:06:39] meet institutional level
[1:06:40] of care,
[1:06:41] which means that they
[1:06:42] qualify to be admitted
[1:06:43] and to live in facilities
[1:06:45] and in institutions.
[1:06:47] IHSS services
[1:06:49] assist people
[1:06:50] with living safely at home.
[1:06:52] These services include
[1:06:53] things like helping
[1:06:55] with bathing,
[1:06:56] with grooming,
[1:06:57] with hygiene,
[1:06:58] with meal preparation,
[1:07:00] and paramedical supports,
[1:07:01] such as changing
[1:07:03] colostomy bags,
[1:07:04] injections,
[1:07:05] medication administration,
[1:07:07] and driving recipients
[1:07:08] to doctor's appointments.
[1:07:10] So without these services,
[1:07:12] children would be living
[1:07:13] in facilities,
[1:07:14] and adults and seniors
[1:07:16] would also be living
[1:07:17] in facilities.
[1:07:18] And these are also
[1:07:20] cost-effective services.
[1:07:21] It's a good use
[1:07:22] of taxpayer dollars
[1:07:23] to invest in these services.
[1:07:25] Every year that we provide
[1:07:27] in-home supportive services
[1:07:28] and keep someone
[1:07:29] out of a nursing facility,
[1:07:31] we save state
[1:07:32] and federal taxpayers
[1:07:33] approximately $100,000.
[1:07:35] I appreciate it.
[1:07:36] And I, you know,
[1:07:37] institutionalization
[1:07:38] is not only terrible,
[1:07:40] but costs so much more money.
[1:07:41] So Mr. Bassieri,
[1:07:43] you said the effects
[1:07:43] of paperwork requirements
[1:07:45] could be, quote,
[1:07:45] catastrophic for New York.
[1:07:47] What impact will these requirements
[1:07:49] have on patients
[1:07:50] and providers
[1:07:50] in New York's Medicaid program?
[1:07:52] And you've only got
[1:07:53] about 45 seconds to answer.
[1:07:56] Thank you for the question,
[1:07:57] Ranking Member Pallone.
[1:07:59] I believe you're referring
[1:08:01] to the implementation
[1:08:02] of community engagement
[1:08:03] requirements,
[1:08:04] which we are set to do
[1:08:06] on January 1st of this year.
[1:08:08] I think the biggest challenge
[1:08:10] is communicating effectively
[1:08:11] and accurately
[1:08:12] with our members
[1:08:13] about the changes
[1:08:14] that are forthcoming
[1:08:15] and the varied nature
[1:08:18] of those changes
[1:08:19] at different time periods.
[1:08:20] We are incurring
[1:08:21] about a 20% increase
[1:08:23] in administrative costs
[1:08:24] to accommodate
[1:08:25] some of the implementation
[1:08:28] requirements
[1:08:29] to mitigate from consumers,
[1:08:31] but we are taking
[1:08:32] proactive steps
[1:08:33] to make sure
[1:08:34] we're making sure
[1:08:35] people are aware
[1:08:36] of the changes.
[1:08:37] We don't want any disruptions
[1:08:38] in continuity of care,
[1:08:39] and that's where
[1:08:40] our focus has been.
[1:08:42] Thank you.
[1:08:42] Thank you, Mr. Chairman.
[1:08:44] I yield that.
[1:08:44] The gentleman yields.
[1:08:46] The chair now recognizes
[1:08:47] the vice chairman
[1:08:48] of the subcommittee,
[1:08:49] Mr. Balderson,
[1:08:50] for his five minutes
[1:08:51] of questioning.
[1:08:52] Thank you, Mr. Chairman,
[1:08:53] and I thank all of you
[1:08:54] for being here today.
[1:08:55] This is a very challenging
[1:08:57] subject to talk about,
[1:08:58] and I reiterate
[1:09:00] what the chairman said
[1:09:01] during his statement,
[1:09:02] so relax,
[1:09:04] breathe a little bit,
[1:09:05] all of you,
[1:09:06] and just let's do
[1:09:08] the best we can here
[1:09:09] and work together.
[1:09:11] Mr. Bartika,
[1:09:13] November 2025,
[1:09:14] seven months into this,
[1:09:16] this has been quite
[1:09:17] an interesting challenge
[1:09:19] for you,
[1:09:20] and I appreciate
[1:09:20] the work that you've done
[1:09:21] in the great state of Ohio
[1:09:22] and the state
[1:09:23] that I am blessed
[1:09:24] and fortunate to represent.
[1:09:27] This committee implemented
[1:09:28] robust Medicaid program
[1:09:30] integrity reform
[1:09:31] in last year's
[1:09:32] working families
[1:09:33] tax cut legislation.
[1:09:34] You mentioned some of that.
[1:09:36] Can you share
[1:09:37] how the Ohio Department
[1:09:38] of Medicaid
[1:09:39] has benefited
[1:09:40] from these reforms so far?
[1:09:41] Thank you, Congressman.
[1:09:46] Yes, as referred to
[1:09:48] in my testimony
[1:09:49] around the benefits
[1:09:50] from that,
[1:09:51] one of the frequent
[1:09:51] audit findings we had
[1:09:52] was interaccuracies
[1:09:54] around member agility.
[1:09:56] The working family
[1:09:57] tax cut legislation
[1:09:58] increased the frequency
[1:09:59] of those redeterminations
[1:10:01] of individuals,
[1:10:02] which will increase
[1:10:02] the accuracy of our roles
[1:10:04] as well as work requirements
[1:10:05] and additional supports
[1:10:07] around identifying
[1:10:08] individuals enrolled
[1:10:09] in multiple states,
[1:10:11] which, as we look
[1:10:12] across the board,
[1:10:12] is producing a significant savings
[1:10:14] to the ongoing state budget
[1:10:16] as we move forward.
[1:10:17] Okay, thank you.
[1:10:19] Ohio recently announced steps
[1:10:20] to build a national model
[1:10:22] of federal and state
[1:10:23] cooperation on fraud enforcement.
[1:10:26] What does this
[1:10:27] federal-state partnership
[1:10:28] look like?
[1:10:29] Could you explain a little bit?
[1:10:31] Yes, Congressman.
[1:10:32] Yes, the effort,
[1:10:34] I think,
[1:10:34] is a great reflection
[1:10:35] of the longstanding work
[1:10:36] that Ohio has had
[1:10:37] between the department
[1:10:39] from the administrative perspective
[1:10:40] and our law enforcement partners
[1:10:42] at the attorney generals
[1:10:43] and at the federal level.
[1:10:45] A longstanding history
[1:10:46] of convictions.
[1:10:47] Over 2,000 individuals
[1:10:48] since 2011
[1:10:49] have been convicted.
[1:10:51] Upon recent trends
[1:10:52] that we have found
[1:10:54] in this area,
[1:10:55] we have started to move
[1:10:55] from this caught-and-stop policy
[1:10:57] to say,
[1:10:57] how can we go upstream
[1:10:59] and start to close doors
[1:11:00] before fraudsters
[1:11:01] enter our program?
[1:11:03] In the wake
[1:11:03] of recent trends
[1:11:04] we have seen,
[1:11:04] we were collaborating
[1:11:05] very closely
[1:11:06] with our partners at CMS
[1:11:08] from new data sharing agreements
[1:11:10] to having robust conversations
[1:11:12] around how to handle
[1:11:13] a provider suspension
[1:11:14] to stop the bleed
[1:11:16] where appropriate
[1:11:17] but also be cognizant
[1:11:18] and aware
[1:11:19] of individuals
[1:11:20] who need to continue
[1:11:21] to receive care.
[1:11:22] That all has culminated
[1:11:24] into the recent efforts.
[1:11:27] Most recently,
[1:11:28] the federal government
[1:11:29] has been rolling out
[1:11:30] a new dashboard
[1:11:31] that compares states
[1:11:32] and compares risk
[1:11:33] of certain services
[1:11:34] that is serving
[1:11:35] for a good guiding tool
[1:11:36] as we look and say,
[1:11:37] what are the anomalies
[1:11:38] in Ohio?
[1:11:39] Is that inconsistent
[1:11:40] with what we're seeing
[1:11:41] across state lines
[1:11:42] which is a new way
[1:11:43] of looking at things?
[1:11:44] It's evolving
[1:11:44] and we plan to continue
[1:11:46] to respond
[1:11:47] as we move forward.
[1:11:48] All right.
[1:11:49] Thank you.
[1:11:49] Well done.
[1:11:51] Ms. Particchio,
[1:11:52] a recent article
[1:11:53] explained how Ohio's Medicaid
[1:11:54] paid more than $5 million
[1:11:56] to a company
[1:11:57] whose president
[1:11:58] had a daycare shutdown
[1:11:59] because of signs of fraud
[1:12:01] and her husband
[1:12:02] has a felony conviction
[1:12:04] for billing
[1:12:04] for non-existent
[1:12:05] elder services.
[1:12:07] How is Ohio reforming
[1:12:08] its provider enrollment
[1:12:10] and revalidation process
[1:12:11] to detect known criminals
[1:12:13] that may be operating
[1:12:15] in concert
[1:12:15] with Medicaid providers?
[1:12:19] Congressman,
[1:12:20] as I mentioned,
[1:12:20] recent legislation
[1:12:21] increased the frequency
[1:12:22] of those revalidations
[1:12:24] as one particular tool.
[1:12:26] I know in instances
[1:12:27] where we find individuals
[1:12:28] have committed
[1:12:29] a past violation
[1:12:30] that was not captured
[1:12:31] upon enrollment
[1:12:32] is one of the areas
[1:12:33] I think from a data sharing
[1:12:35] perspective across state lines
[1:12:36] would be incredibly helpful
[1:12:38] to know from across
[1:12:39] multiple programs,
[1:12:40] not just Medicaid
[1:12:41] but also Medicare.
[1:12:43] In Ohio,
[1:12:44] we are proactively
[1:12:45] starting to share
[1:12:46] this information
[1:12:46] with our partners
[1:12:47] at other state agencies
[1:12:48] not to determine
[1:12:51] if there is a potential
[1:12:52] for fraud, waste,
[1:12:53] and abuse
[1:12:53] in other programs
[1:12:54] as we see individuals
[1:12:55] involved in not just
[1:12:56] Medicaid services
[1:12:57] but perhaps
[1:12:58] daycare services
[1:12:59] and the like.
[1:13:01] Okay.
[1:13:01] And we're down
[1:13:02] in about 50 seconds,
[1:13:02] Mr. Particchio.
[1:13:03] What considerations
[1:13:05] are being made
[1:13:06] in Ohio
[1:13:06] if any
[1:13:07] to reassess
[1:13:09] Medicaid-only provider
[1:13:10] categorically risk
[1:13:11] types
[1:13:12] after fraud
[1:13:13] allegations
[1:13:14] and charges
[1:13:15] that have recently
[1:13:16] been made?
[1:13:18] Congressman,
[1:13:18] one of the
[1:13:19] revalidation plan
[1:13:21] that we have submitted
[1:13:22] to CMS
[1:13:22] in particular
[1:13:23] looking at
[1:13:24] the categories
[1:13:25] of risk
[1:13:26] but also looking at
[1:13:27] how can we do
[1:13:27] a data dive
[1:13:28] to not just determine
[1:13:29] what type of provider
[1:13:30] they are
[1:13:30] but what is the behavior
[1:13:31] of that provider?
[1:13:32] What are the billing patterns?
[1:13:33] Are they massive outliers
[1:13:34] from others
[1:13:35] and moving them
[1:13:36] into high-risk category
[1:13:37] based on behavior?
[1:13:39] Moving into a high-risk category
[1:13:40] of course does not mean
[1:13:41] you are fraudulent
[1:13:41] on its face.
[1:13:43] It means you require
[1:13:44] additional investigation
[1:13:45] and oversight
[1:13:45] on a more frequent basis.
[1:13:47] All right.
[1:13:47] Thank you very much,
[1:13:48] Mr. Chairman.
[1:13:48] I yield back.
[1:13:49] Thank you all
[1:13:49] for being here.
[1:13:51] The gentleman yields.
[1:13:52] The chair now recognizes
[1:13:53] Ms. DeGette
[1:13:54] for her five minutes
[1:13:55] of questioning.
[1:13:56] Thank you so much,
[1:13:56] Mr. Chairman.
[1:13:57] And I want to thank
[1:13:58] the witnesses
[1:13:58] for being here.
[1:14:00] All of you are taking time
[1:14:01] out of your busy schedules
[1:14:02] and we appreciate it
[1:14:03] because you don't have
[1:14:04] an easy job.
[1:14:06] I would imagine
[1:14:07] that a large part
[1:14:08] of what you do is try
[1:14:10] to integrate your programs
[1:14:12] with CMS
[1:14:13] and the other executive branch agencies
[1:14:16] and I would imagine
[1:14:17] it would help
[1:14:18] if it was that collaborative.
[1:14:20] So I have a long list
[1:14:21] of questions.
[1:14:22] I would appreciate yes
[1:14:23] or no answers
[1:14:24] and you do not need
[1:14:26] to thank me
[1:14:26] for the questions.
[1:14:27] Mr. Partika,
[1:14:28] I want to start with you.
[1:14:30] Has CMS been collaborative
[1:14:32] with Ohio
[1:14:33] in pursuing anti-fraud initiatives?
[1:14:37] Yes, ma'am.
[1:14:38] Earlier this month,
[1:14:39] DOJ announced a collaborative
[1:14:41] federal-state partnership
[1:14:42] with Ohio to combat fraud.
[1:14:44] Is that correct?
[1:14:46] Yes.
[1:14:47] And during this administration,
[1:14:49] has CMS sent Ohio
[1:14:50] a formal inquiry
[1:14:52] regarding the state's
[1:14:53] anti-fraud policies?
[1:14:58] Has CMS sent Ohio
[1:15:00] a formal inquiry
[1:15:02] regarding the state's
[1:15:03] anti-fraud policies?
[1:15:04] And I will have to confirm
[1:15:06] we've had various inquiries
[1:15:07] from CMS.
[1:15:07] Oh, you don't know.
[1:15:08] Okay.
[1:15:09] Dr. Connolly,
[1:15:10] on December 5th, 2025,
[1:15:13] CMS sent Minnesota
[1:15:14] a letter demanding
[1:15:16] a corrective action plan.
[1:15:17] Is that correct?
[1:15:19] You need to turn
[1:15:20] your mic on.
[1:15:21] Yes.
[1:15:21] You submitted
[1:15:22] a corrective action plan
[1:15:23] to CMS
[1:15:24] by the deadline
[1:15:25] they provided
[1:15:25] and then your office
[1:15:27] met with CMS
[1:15:28] on January 6th
[1:15:29] to discuss that plan.
[1:15:30] Is that correct?
[1:15:32] I'd have to confirm
[1:15:33] the date of the meeting,
[1:15:34] but yes.
[1:15:34] Yeah, you met with them.
[1:15:35] Later that same day
[1:15:36] on January 6th,
[1:15:38] Administrator Oz announced
[1:15:39] CMS would withhold
[1:15:40] up to $2 billion
[1:15:42] from Minnesota.
[1:15:43] Did the agency
[1:15:44] give you any indication
[1:15:46] it was about to make
[1:15:47] a significant funding threat
[1:15:49] just hours later?
[1:15:51] Not in advance
[1:15:51] of the meeting in January.
[1:15:52] Thank you.
[1:15:53] And also, Dr. Connolly,
[1:15:55] is it true
[1:15:56] that after receiving
[1:15:57] additional questions
[1:15:58] from CMS,
[1:15:59] Minnesota submitted
[1:16:00] a revised corrective action plan
[1:16:02] on January 20th
[1:16:04] and met with CMS
[1:16:05] on February 3rd,
[1:16:06] February 10th,
[1:16:07] February 17th,
[1:16:09] and February 24th?
[1:16:11] Yes, I believe that's true.
[1:16:12] And on February 25th,
[1:16:14] after four weeks
[1:16:15] of refusing
[1:16:15] to provide Minnesota feedback
[1:16:17] on its plan,
[1:16:18] Administrator Oz announced
[1:16:19] he was deferring
[1:16:21] $259 million
[1:16:23] in Medicare funding.
[1:16:25] During your four meetings,
[1:16:26] Dr. Connolly,
[1:16:27] with CMS,
[1:16:28] in February alone,
[1:16:29] did the agency
[1:16:30] ever provide notice
[1:16:32] that it was planning
[1:16:33] to defer nearly
[1:16:34] a quarter billion dollars
[1:16:35] in funding?
[1:16:37] I personally was not
[1:16:38] given that information.
[1:16:40] You don't think so, right?
[1:16:42] I personally was not aware
[1:16:44] of that coming, no.
[1:16:44] Okay.
[1:16:45] Mr. Sadwith,
[1:16:46] California had a $1.3 billion
[1:16:49] deferral from CMS.
[1:16:51] Did CMS provide you
[1:16:52] with any notice
[1:16:53] of the incoming deferral
[1:16:54] or any concrete things
[1:16:56] you could do to prevent it?
[1:16:59] CMS asked questions
[1:17:01] and we responded to them.
[1:17:03] But they didn't tell you
[1:17:04] what to do, right?
[1:17:05] Correct.
[1:17:06] Has CMS told you anything
[1:17:07] about what your state
[1:17:09] needs to do
[1:17:09] to get that critical funding released?
[1:17:12] CMS continues to pose
[1:17:14] questions to us
[1:17:15] and we continue.
[1:17:15] So they haven't told you
[1:17:16] what you need to do
[1:17:17] to get it released,
[1:17:18] yes or no?
[1:17:19] No.
[1:17:20] And is this a departure
[1:17:21] from how CMS
[1:17:22] and California have collaborated
[1:17:23] in the past?
[1:17:25] Yes.
[1:17:25] Thank you.
[1:17:26] So CMS, in my view,
[1:17:29] is going out of its way
[1:17:30] to blindside blue states
[1:17:32] while pampering red ones.
[1:17:34] In fact, CMS has sent letters
[1:17:36] investigating Medicaid programs
[1:17:38] in New York, California,
[1:17:40] Maine, Minnesota, and Florida.
[1:17:42] Florida's letter is a fig leaf
[1:17:44] to pretend the agency's investigations
[1:17:46] were not partisan
[1:17:47] coming minutes
[1:17:49] before CMS leadership
[1:17:50] was to set to appear
[1:17:52] before this subcommittee.
[1:17:54] Soon after sending the letter
[1:17:56] to Florida, however,
[1:17:57] Dr. Oz took to social media
[1:17:59] to praise the DeSantis administration.
[1:18:02] Only blue states
[1:18:03] have had their Medicaid funding
[1:18:05] deferred or threatened
[1:18:06] and CMS has shown no evidence
[1:18:08] that these states
[1:18:09] are worse actors.
[1:18:10] Frankly, unfortunately,
[1:18:12] this is a staged performance
[1:18:13] to target blue states,
[1:18:15] not a genuine fraud investigation.
[1:18:17] It's exemplary
[1:18:18] of how this whole administration works
[1:18:20] and how hollow
[1:18:21] the administration's focus
[1:18:23] on fraud really is.
[1:18:25] Donald Trump has pardoned
[1:18:27] or commuted the sentences
[1:18:28] of several convicted fraudsters
[1:18:30] who seem to be his supporters.
[1:18:33] Lawrence Duran
[1:18:33] stole $205 million
[1:18:36] from Medicare
[1:18:37] and was sentenced
[1:18:38] to 50 years in prison,
[1:18:40] sentenced commuted.
[1:18:41] Paul Walczak stole money
[1:18:43] from the employees
[1:18:43] of his nursing home.
[1:18:45] President Trump pardoned him
[1:18:46] in April 2025
[1:18:48] after his mother
[1:18:49] attended a million-dollar person
[1:18:51] fundraiser at Mar-a-Lago.
[1:18:54] We can figure this out.
[1:18:55] I'm reminded of an old phrase
[1:18:58] that sums up everything
[1:18:59] this administration
[1:19:00] is all about.
[1:19:01] Amicus omnia
[1:19:02] intimesis legis.
[1:19:06] To my friends, everything.
[1:19:07] To my enemies, the law.
[1:19:10] I yield back.
[1:19:11] General Lady Yields.
[1:19:12] The chair now recognizes
[1:19:13] Mr. Palmer
[1:19:14] for his five minutes
[1:19:15] of questioning.
[1:19:16] My first three questions
[1:19:17] are yes or no answer.
[1:19:18] You do not have to thank me
[1:19:19] for the question.
[1:19:21] Given that providers
[1:19:22] engaged in fraud,
[1:19:23] waste, and abuse
[1:19:24] that may involve
[1:19:26] being enrolled
[1:19:27] in both Medicare
[1:19:27] and Medicaid,
[1:19:28] does your state
[1:19:29] share information
[1:19:30] between the two programs
[1:19:32] to prevent enrollment
[1:19:32] of bad actors,
[1:19:34] Mr. Connolly?
[1:19:36] I'm sorry,
[1:19:37] are we sharing information
[1:19:39] with the Medicare program?
[1:19:41] To ensure that
[1:19:42] you don't have
[1:19:42] fraudulent dual enrollment
[1:19:45] in Medicare and Medicaid.
[1:19:46] We are sharing information
[1:19:47] weekly with the Centers
[1:19:48] for Medicare and Medicaid Services.
[1:19:50] It's a yes.
[1:19:50] Mr. Sadwick?
[1:19:53] Yes, we share information
[1:19:54] with CMS.
[1:19:54] Mr. Bessieri?
[1:19:56] Yes, we share information.
[1:19:57] Mr. Batryka?
[1:19:59] Yes, sir.
[1:20:00] Okay, does your state
[1:20:01] share information
[1:20:01] with the Treasuries
[1:20:02] Do Not Pay system
[1:20:03] or other federal databases?
[1:20:05] Mr. Connolly?
[1:20:07] I'm sorry,
[1:20:07] could you repeat the question?
[1:20:09] I know I have
[1:20:09] a southern accent.
[1:20:10] I'll try to speak
[1:20:12] a little clearly.
[1:20:13] Does your state
[1:20:14] share this information
[1:20:15] with the Treasuries
[1:20:16] Do Not Pay system?
[1:20:18] I'd have to confirm
[1:20:19] whether or not
[1:20:20] we've done that.
[1:20:20] Mr. Sadwick?
[1:20:22] Our state collaborates
[1:20:23] with CMS
[1:20:24] to share tax information.
[1:20:25] Sounds like you don't
[1:20:26] even know what
[1:20:27] I'm talking about.
[1:20:27] Mr. Bessieri?
[1:20:30] I am happy
[1:20:31] to take that back
[1:20:32] and confirm.
[1:20:32] Okay, find out.
[1:20:33] Mr. Batryka?
[1:20:35] I'm sorry, sir.
[1:20:36] I'll have to provide
[1:20:36] follow-up on that question.
[1:20:37] Okay.
[1:20:39] Does your state
[1:20:39] work to share
[1:20:40] this information
[1:20:40] across state lines
[1:20:41] to ensure
[1:20:42] that you don't have
[1:20:42] people enrolled
[1:20:43] in your states
[1:20:44] that are enrolled
[1:20:45] in other states?
[1:20:46] Mr. Connolly?
[1:20:48] Yes, that is part
[1:20:48] of a regular exercise.
[1:20:49] Thank you.
[1:20:49] Mr. Sadwick?
[1:20:51] We share information
[1:20:52] on eligibility
[1:20:53] that is...
[1:20:54] It sounds like
[1:20:54] you don't know
[1:20:55] Mr. Bessieri.
[1:20:57] We do.
[1:20:58] Thank you.
[1:20:59] Mr. Batryka?
[1:21:02] I apologize.
[1:21:06] I'd have to confirm
[1:21:07] that we share with CMS.
[1:21:08] Mr. Connolly, CMS
[1:21:11] asked that you
[1:21:12] revalidate all providers
[1:21:14] in the 14 high-risk
[1:21:15] Medicaid programs.
[1:21:16] There's nearly 5,600 providers.
[1:21:19] After the initial revalidation,
[1:21:21] your office reported
[1:21:22] it disenrolled
[1:21:22] more than 3,400 providers.
[1:21:24] That's 60%
[1:21:25] of those enrolled.
[1:21:27] However, last week,
[1:21:28] it appears your agency
[1:21:28] restored the billing privileges
[1:21:30] for over 2,100
[1:21:31] that submitted the appeals.
[1:21:33] What's going on
[1:21:34] with this revalidation process,
[1:21:36] and how are you making sure
[1:21:37] that providers
[1:21:37] were restored pending a pill
[1:21:39] or filing legitimate claims
[1:21:41] in the meantime?
[1:21:43] To preserve continuity
[1:21:44] of service
[1:21:44] for the beneficiaries...
[1:21:46] What are you doing
[1:21:47] to make sure
[1:21:47] that they're not filing
[1:21:48] illegitimate claims?
[1:21:50] All of those services
[1:21:51] are subject
[1:21:52] to enhanced prepayment review
[1:21:53] and all of the high-risk
[1:21:56] designation requirements
[1:21:57] that are associated with it.
[1:21:58] Of the 3,400 providers
[1:22:00] who were initially disenrolled,
[1:22:02] when were those providers
[1:22:03] last revalidated?
[1:22:05] Was it within
[1:22:05] the last five years?
[1:22:08] Yes, all providers
[1:22:08] have to revalidate
[1:22:09] within five years.
[1:22:11] It's also been reported
[1:22:12] that many of the providers
[1:22:13] that were disenrolled
[1:22:14] had been flagged
[1:22:15] by your agency before.
[1:22:16] Is that true?
[1:22:18] I'm sorry,
[1:22:18] could you repeat the question?
[1:22:20] It's also been reported
[1:22:22] that many of the providers
[1:22:23] that were disenrolled
[1:22:24] had been flagged
[1:22:25] by your agency before.
[1:22:26] In other words,
[1:22:27] there was some suspicion
[1:22:29] is that true,
[1:22:31] had they been flagged before?
[1:22:34] I'd have to confirm
[1:22:35] the details of that for you.
[1:22:37] All right.
[1:22:38] Did your agency
[1:22:41] ascertain whether
[1:22:42] the providers
[1:22:42] that were disenrolled
[1:22:43] when re-enrolled
[1:22:45] pending appeal
[1:22:45] were providers
[1:22:46] that had been
[1:22:47] previously flagged
[1:22:48] for fraud?
[1:22:50] Providers that are flagged
[1:22:51] for fraud
[1:22:52] have a payment withhold
[1:22:53] applied
[1:22:54] and those cases
[1:22:57] are sent to law enforcement.
[1:22:57] So you're saying
[1:22:58] that none of the ones
[1:22:59] that have had
[1:23:01] their billing privileges
[1:23:02] restored
[1:23:02] were flagged
[1:23:05] for fraud in the past?
[1:23:06] If we are aware,
[1:23:07] our inspector general
[1:23:08] is aware
[1:23:09] of a credible allegation
[1:23:10] of fraud,
[1:23:10] there would be
[1:23:11] a payment withhold
[1:23:11] and they would be
[1:23:12] referred to law enforcement
[1:23:13] for investigation
[1:23:14] and prosecution.
[1:23:15] Can you confirm
[1:23:16] that your agency
[1:23:16] is conducting
[1:23:17] this validation
[1:23:18] in a thorough manner
[1:23:21] and that no providers
[1:23:22] being revalidated
[1:23:23] are fraudulent
[1:23:24] or have been flagged
[1:23:25] as potentially fraudulent?
[1:23:27] Our team is being
[1:23:28] very exacting,
[1:23:29] making sure that providers
[1:23:30] meet all the compliance
[1:23:31] requirements.
[1:23:32] The thing I want
[1:23:33] to make certain here
[1:23:34] is that none of us
[1:23:36] on this side of the aisle
[1:23:37] want to deny services
[1:23:40] to anybody
[1:23:41] who legitimately needs it.
[1:23:43] What this is really about
[1:23:44] is that there have been
[1:23:46] billions of dollars
[1:23:47] stolen from state
[1:23:48] and federal programs
[1:23:49] that should have gone
[1:23:50] to help people
[1:23:52] who legitimately need them.
[1:23:54] That's the shame of this.
[1:23:56] That's the tragedy of this,
[1:23:58] is that there are people
[1:23:59] who need these services
[1:24:01] that don't,
[1:24:02] that are having to have
[1:24:03] limited compensation,
[1:24:05] limited access
[1:24:06] because so much money
[1:24:08] has been stolen.
[1:24:09] That's what this is about
[1:24:10] and that's why we're going
[1:24:11] to get to the bottom of it,
[1:24:13] correct it,
[1:24:13] so that people
[1:24:13] who should be getting
[1:24:14] the funding for these services
[1:24:16] get what they're supposed
[1:24:18] to get.
[1:24:18] I yield back.
[1:24:21] The gentleman yields.
[1:24:22] The chair now recognizes
[1:24:23] Mr. Tonko
[1:24:24] for his five minutes
[1:24:25] of questioning.
[1:24:28] Thank you, Mr. Chair.
[1:24:30] We've heard all of you
[1:24:32] express how your states
[1:24:34] value the federal-state
[1:24:35] collaboration
[1:24:36] to manage your Medicaid programs
[1:24:38] and we've heard the same
[1:24:39] from other witnesses
[1:24:40] on this topic
[1:24:41] in prior hearings.
[1:24:43] It is clear
[1:24:43] that the Medicaid program
[1:24:44] cannot work
[1:24:45] without a productive partnership
[1:24:47] between the federal government
[1:24:49] and the states.
[1:24:51] But CMS has abruptly shifted
[1:24:52] from providing support
[1:24:53] to states
[1:24:54] toward creating obstacles
[1:24:56] for them,
[1:24:57] or at least for certain states
[1:24:58] that did not support
[1:25:00] the president
[1:25:00] in the last election.
[1:25:02] So, Mr. Basiri,
[1:25:04] New York has received scrutiny
[1:25:05] and threats directly
[1:25:07] from Dr. Oz
[1:25:08] about its Medicaid funding.
[1:25:10] It turns out that CMS
[1:25:11] had an analysis
[1:25:13] that led to these threats
[1:25:14] and questions
[1:25:15] and it was completely faulty.
[1:25:20] However, Mr. Basiri,
[1:25:21] how important is it
[1:25:22] to state anti-fraud efforts
[1:25:24] to have CMS operate
[1:25:26] as a good-faith partner
[1:25:27] rather than a bad-faith antagonist?
[1:25:30] Thank you for the question,
[1:25:34] Congressman.
[1:25:35] Partnership is paramount
[1:25:36] to addressing and combating
[1:25:37] fraud waste and abuse.
[1:25:40] I think our work
[1:25:41] with CMS is ongoing
[1:25:44] and is focused
[1:25:45] on high-risk areas.
[1:25:47] However, I think
[1:25:49] it's important to note
[1:25:50] that the working relationship
[1:25:52] is necessary
[1:25:53] to systematically root out
[1:25:55] any fraud waste and abuse
[1:25:56] and ensure that that fraud
[1:25:58] doesn't persist elsewhere.
[1:26:00] We do have complex programs
[1:26:02] and as others have mentioned
[1:26:04] on the panel,
[1:26:05] it's not just one area.
[1:26:06] Things can be in multiple areas,
[1:26:08] so that federal partnership
[1:26:10] is key and critical
[1:26:12] to our ability
[1:26:12] to successfully address
[1:26:14] program integrity.
[1:26:15] Thank you.
[1:26:16] And Dr. Connolly,
[1:26:16] your department has been
[1:26:18] in talks with CMS
[1:26:19] for over six months
[1:26:20] regarding the CMS withholding
[1:26:23] of your state's
[1:26:24] corrective action plan
[1:26:25] and subsequent deferrals
[1:26:26] of funding.
[1:26:27] In April,
[1:26:27] you said about these talks
[1:26:29] and I quote,
[1:26:30] the goalposts keep moving
[1:26:31] rather than work with us
[1:26:33] to fight fraud
[1:26:34] while protecting programs.
[1:26:36] CMS is taking actions
[1:26:37] that punish Minnesotans
[1:26:38] who need these services.
[1:26:40] Since that statement,
[1:26:41] CMS has taken yet another deferral
[1:26:44] against your state's
[1:26:45] Medicaid program.
[1:26:46] So can you explain
[1:26:47] what your interactions
[1:26:48] have been like
[1:26:49] with CMS regarding
[1:26:50] your program integrity efforts
[1:26:52] and whether CMS
[1:26:53] has been consistent
[1:26:54] and clear
[1:26:55] in what it needs you
[1:26:57] to provide
[1:26:57] in order to release
[1:26:58] the deferred funds?
[1:27:02] So we've been engaged
[1:27:03] very regularly with CMS
[1:27:04] since December 5th,
[1:27:05] the initial letter
[1:27:06] from Administrator Oz
[1:27:08] requesting,
[1:27:09] really directing us
[1:27:10] to develop
[1:27:10] a corrective action plan
[1:27:12] that was submitted
[1:27:12] after the first draft
[1:27:14] was submitted
[1:27:15] on the 31st of December 2025
[1:27:17] at the end of January
[1:27:19] in 2026.
[1:27:19] We met for multiple months
[1:27:22] weekly with CMS
[1:27:23] to make sure
[1:27:25] that we were fulfilling
[1:27:26] their requirements,
[1:27:28] providing deliverables,
[1:27:29] meeting milestones on time,
[1:27:31] and our team has worked
[1:27:32] days, nights, weekends,
[1:27:34] holidays to do that.
[1:27:35] In addition,
[1:27:37] beyond the first
[1:27:38] corrective action plan direction,
[1:27:40] the second required revision
[1:27:42] of the corrective action plan
[1:27:43] and the compliance action
[1:27:44] in January,
[1:27:45] there was,
[1:27:46] as you noted,
[1:27:46] the deferral issued
[1:27:48] and the focus review
[1:27:48] initiated in February.
[1:27:51] So there have been
[1:27:52] multiple different
[1:27:53] additional actions
[1:27:55] after the first in December
[1:27:57] and we continue
[1:27:58] to work with them
[1:27:59] continuously
[1:28:00] and at their request
[1:28:02] to meet all of the milestones,
[1:28:04] provide all of the deliverables,
[1:28:06] meet the marks
[1:28:06] so that we can be released
[1:28:08] from those compliance actions
[1:28:10] and deferrals.
[1:28:11] But the consistency
[1:28:12] and clarity here
[1:28:13] are important, obviously,
[1:28:15] in order for the partnership
[1:28:17] to work on behalf
[1:28:18] of the consumer
[1:28:19] and the taxpayer.
[1:28:21] In your testimony,
[1:28:22] you note that your state's
[1:28:23] anti-fraud policies
[1:28:24] have been mischaracterized
[1:28:26] by federal officials
[1:28:27] and that those public statements
[1:28:28] erode trust
[1:28:29] in the federal-state partnership
[1:28:31] and carry risks
[1:28:32] to care.
[1:28:34] So, Dr. Connolly,
[1:28:35] have you tried to correct
[1:28:37] the mischaracterizations
[1:28:38] with CMS?
[1:28:39] And if so,
[1:28:40] what has been the reception
[1:28:41] from CMS officials?
[1:28:45] Thank you for the question,
[1:28:46] Representative Tonko.
[1:28:47] We continuously try
[1:28:49] to correct mischaracterizations
[1:28:51] both through public statements
[1:28:53] but also through written statements
[1:28:56] in addition to our program
[1:28:57] integrity dashboard
[1:28:58] and website
[1:28:59] on our department's website.
[1:29:01] And how do you respond
[1:29:02] to remarks
[1:29:03] that Secretary Kennedy,
[1:29:04] Administrator Oz,
[1:29:05] and Vice President Vance
[1:29:06] have made
[1:29:07] that Minnesota
[1:29:08] has not been cooperating
[1:29:11] with the federal government
[1:29:12] to fight Medicaid fraud?
[1:29:13] I would say
[1:29:15] that we reached out
[1:29:17] proactively to CMS
[1:29:18] when we decided
[1:29:20] to designate programs
[1:29:21] or benefits high-risk
[1:29:23] in the first half of 2025.
[1:29:25] We also then engaged them
[1:29:27] to partner on terminating,
[1:29:30] taking the painful step
[1:29:31] of terminating
[1:29:31] the housing stabilization
[1:29:32] services benefit.
[1:29:34] That was at our initiative
[1:29:35] as a state.
[1:29:36] They worked with us on that.
[1:29:37] It was executed
[1:29:38] by the end of October.
[1:29:39] We also designated
[1:29:41] the full 14 services
[1:29:42] as high-risk
[1:29:43] at our initiative.
[1:29:44] And again,
[1:29:45] that's something
[1:29:46] that CMS provides
[1:29:47] the framework for.
[1:29:48] We've continuously
[1:29:48] worked with them.
[1:29:50] And that was well
[1:29:51] in advance
[1:29:51] of the December 5th letter
[1:29:53] from Administrator Oz.
[1:29:54] Okay.
[1:29:55] Mr. Chair,
[1:29:55] I have other questions
[1:29:56] that I'll get to the committee,
[1:29:58] subcommittee.
[1:29:59] But with that,
[1:30:00] I thank you and yield back.
[1:30:01] The gentleman yields.
[1:30:03] The chair now recognizes
[1:30:04] Mr. Allen
[1:30:05] for his five minutes
[1:30:06] of questioning.
[1:30:07] Thank you, Chairman.
[1:30:08] And I thank you
[1:30:09] for being here today
[1:30:10] and informing us
[1:30:13] on what in the world
[1:30:14] is how this took place.
[1:30:17] The first question I have,
[1:30:18] I think all of you
[1:30:19] have admitted
[1:30:21] that you have significant
[1:30:23] waste, fraud, and abuse
[1:30:24] in these programs
[1:30:25] in your states.
[1:30:26] Is that correct?
[1:30:28] Would anyone dispute that?
[1:30:30] I think the question here
[1:30:32] is should taxpayers
[1:30:33] continue to pay
[1:30:35] and be put on the line
[1:30:40] for this waste,
[1:30:41] fraud, and abuse,
[1:30:42] or should the taxpayers
[1:30:43] say, okay, you fix it
[1:30:46] and then we'll be glad
[1:30:47] to fund those
[1:30:48] who by law
[1:30:49] are allowed
[1:30:51] to use these programs?
[1:30:52] That's the question.
[1:30:54] And that's the difference
[1:30:55] of opinion here
[1:30:56] in my mind.
[1:30:58] For all the witnesses,
[1:31:00] ongoing criminal investigations
[1:31:02] in many states
[1:31:03] have identified
[1:31:03] shared ownership
[1:31:04] or affiliations
[1:31:05] where individuals
[1:31:06] are enrolled
[1:31:07] in perpetrating fraud
[1:31:08] in numerous Medicaid
[1:31:10] Medicaid services.
[1:31:13] What exactly
[1:31:14] is your state doing
[1:31:15] to more closely examine,
[1:31:18] concurrently enrolled
[1:31:19] Medicaid providers
[1:31:21] to identify
[1:31:21] shared ownership
[1:31:22] or affiliations
[1:31:23] with excluded providers
[1:31:25] that have previously
[1:31:27] perpetrated fraud?
[1:31:29] That is your responsibility.
[1:31:31] Tell me what you're doing there.
[1:31:33] And I'll start
[1:31:33] with Mr. Connolly.
[1:31:35] Thank you,
[1:31:36] Representative Allen.
[1:31:37] So the first thing
[1:31:38] I would point out
[1:31:38] is that fraud
[1:31:40] is unacceptable.
[1:31:40] We agree with that.
[1:31:42] And we have fought
[1:31:43] very hard
[1:31:44] to root out fraud
[1:31:45] in our programs
[1:31:45] with respect
[1:31:47] to different steps
[1:31:47] taken to find connections
[1:31:50] among bad actors
[1:31:51] or criminals
[1:31:51] in our program
[1:31:52] whom we hope
[1:31:53] are prosecuted
[1:31:54] and go to prison
[1:31:55] because of the fraud
[1:31:56] they're committing.
[1:31:57] We have initiated,
[1:31:59] of course,
[1:31:59] the revalidation effort
[1:32:00] among the high-risk providers
[1:32:03] that we designated.
[1:32:04] So 14 services,
[1:32:05] as I said,
[1:32:06] were designated high-risk.
[1:32:08] They were all subject
[1:32:09] to that revalidation,
[1:32:10] that off-cycle revalidation
[1:32:11] that I mentioned,
[1:32:12] the 5,600.
[1:32:14] And part of that work
[1:32:15] is to identify
[1:32:16] through the fingerprint
[1:32:16] background check,
[1:32:18] through the site visit
[1:32:19] and the review
[1:32:20] of credentials
[1:32:21] and documentation,
[1:32:22] who those providers
[1:32:23] are led by,
[1:32:25] what ownership is,
[1:32:26] and do analysis
[1:32:27] with the appropriate databases
[1:32:28] and work with law enforcement
[1:32:29] to understand
[1:32:30] what connections
[1:32:31] there may be
[1:32:32] among bad actors
[1:32:32] and criminals.
[1:32:33] So we are taking
[1:32:35] that action,
[1:32:36] I think principally,
[1:32:37] but also we do work
[1:32:38] with federal and state
[1:32:39] law enforcement.
[1:32:40] I've got three more
[1:32:40] I need to get to,
[1:32:42] so if we can make
[1:32:42] our answers short.
[1:32:43] And I'm going to have
[1:32:44] a follow-up question
[1:32:45] as well.
[1:32:46] Is,
[1:32:46] are there any elected
[1:32:48] political officials
[1:32:49] in your state
[1:32:50] that are doing
[1:32:51] everything they can do
[1:32:53] to keep you
[1:32:54] from uncovering
[1:32:55] this fraud,
[1:32:56] waste,
[1:32:56] and abuse?
[1:32:57] And of course,
[1:32:58] now,
[1:32:58] I'll go to the next witness.
[1:33:00] Thank you.
[1:33:02] So to address
[1:33:03] your first question,
[1:33:04] fighting fraud
[1:33:05] is a top priority
[1:33:06] for our department,
[1:33:07] and we know fraud
[1:33:08] is not unique
[1:33:08] to Medicaid
[1:33:09] or even Medicare.
[1:33:10] It's also in private
[1:33:11] health insurance,
[1:33:12] and that's why
[1:33:12] we have to work together
[1:33:13] to protect taxpayer dollars.
[1:33:15] Making sure
[1:33:16] that we crack down
[1:33:17] on bad actors
[1:33:18] who have,
[1:33:19] you know,
[1:33:21] use business structuring
[1:33:24] to conceal
[1:33:25] their illicit activity
[1:33:27] is a top priority
[1:33:28] for California.
[1:33:29] We collect
[1:33:31] comprehensive disclosure,
[1:33:33] ownership,
[1:33:33] and control interest
[1:33:34] information
[1:33:35] from every provider
[1:33:37] applying.
[1:33:38] We check those
[1:33:39] against federal
[1:33:39] and state
[1:33:40] exclusionary database lists.
[1:33:42] We also check
[1:33:44] those lists
[1:33:45] for subcontractors
[1:33:47] of those providers
[1:33:48] and other business
[1:33:49] entities
[1:33:50] that they have
[1:33:50] a significant
[1:33:51] business relationship
[1:33:52] with.
[1:33:53] Is it?
[1:33:54] Okay,
[1:33:54] Mr. Bessere.
[1:33:57] Thank you
[1:33:57] for the question,
[1:33:59] Congressman.
[1:34:00] Last year,
[1:34:02] under Governor Hochul's
[1:34:03] leadership,
[1:34:03] we really prioritized
[1:34:05] the development
[1:34:06] and implementation
[1:34:06] of a provider
[1:34:07] services portal,
[1:34:09] which is a new
[1:34:11] provider enrollment
[1:34:12] system,
[1:34:13] and putting that
[1:34:13] in place.
[1:34:14] It is slowly
[1:34:15] rolling out now,
[1:34:17] and as part
[1:34:17] of the revalidation
[1:34:18] plan being requested
[1:34:19] by CMS,
[1:34:21] we are sort of
[1:34:21] expediting that
[1:34:23] implementation plan.
[1:34:24] We are adding
[1:34:25] new Medicaid-only
[1:34:26] providers to high-risk
[1:34:27] designations
[1:34:28] and pursuing
[1:34:29] moratoriums
[1:34:30] where applicable.
[1:34:31] We completely agree
[1:34:32] that the front door
[1:34:33] to the program
[1:34:33] is a very important
[1:34:34] safeguard.
[1:34:35] Good.
[1:34:35] Mr. Duh?
[1:34:37] Yes, Congressman.
[1:34:38] In Ohio,
[1:34:38] when we've identified
[1:34:39] shared ownership,
[1:34:41] indictment of fraud,
[1:34:42] we will take action.
[1:34:43] Recent improvements
[1:34:44] have helped that.
[1:34:45] As folks continue
[1:34:46] to conceal their
[1:34:47] ownership and control
[1:34:48] of entities,
[1:34:49] that is a challenge
[1:34:49] that I think the states
[1:34:50] and federal government
[1:34:51] will be tasked with.
[1:34:52] And yes or no,
[1:34:53] this all happened
[1:34:53] in the last year
[1:34:54] when this was brought
[1:34:57] to the public eye.
[1:35:00] It's been a year.
[1:35:01] And my question is,
[1:35:02] did the Biden
[1:35:03] administration
[1:35:03] notify you
[1:35:05] of any of these issues
[1:35:06] when they were
[1:35:10] in charge of CMS?
[1:35:14] Did you get any
[1:35:15] requests for them
[1:35:17] for identification
[1:35:19] of waste, fraud,
[1:35:20] and abuse?
[1:35:22] These processes
[1:35:22] have been in place
[1:35:23] in California.
[1:35:24] They're not new.
[1:35:25] And yes,
[1:35:25] we did collaborate
[1:35:26] with the Center
[1:35:27] for Program Integrity
[1:35:28] at CMS.
[1:35:28] But it was not
[1:35:30] publicly known
[1:35:31] at that time,
[1:35:32] I don't believe.
[1:35:33] Is that correct?
[1:35:36] Okay, well,
[1:35:36] I'm out of time
[1:35:37] and I'll yield back,
[1:35:37] Mr. Chairman.
[1:35:38] The gentleman yields.
[1:35:39] The chair now recognizes
[1:35:40] Ms. Trahan
[1:35:41] for her five minutes
[1:35:42] of questioning.
[1:35:43] Thank you,
[1:35:43] Mr. Chairman.
[1:35:44] And thank you all
[1:35:45] for being here today.
[1:35:47] Republicans have made
[1:35:48] state Medicaid programs
[1:35:49] nearly impossible
[1:35:50] to administer.
[1:35:52] Their so-called efforts
[1:35:53] to root out
[1:35:53] waste, fraud,
[1:35:54] and abuse
[1:35:55] have only created
[1:35:56] more bureaucracy,
[1:35:57] more costs,
[1:35:58] and more money
[1:35:59] diverted
[1:36:00] from patient care.
[1:36:01] Meanwhile,
[1:36:02] hospitals across the country
[1:36:03] continue to close.
[1:36:05] Providers worry
[1:36:05] about making payroll.
[1:36:07] And Americans
[1:36:08] with disabilities
[1:36:09] wonder whether they'll
[1:36:09] be able to get
[1:36:10] the care that they need.
[1:36:11] This year,
[1:36:12] CMS has attacked
[1:36:14] providers of home
[1:36:15] and community-based services,
[1:36:17] sending shockwaves
[1:36:18] for caregivers
[1:36:19] and patients
[1:36:20] across the country.
[1:36:21] In the district
[1:36:22] I represent,
[1:36:23] UMass Memorial
[1:36:24] has worked with MassHealth
[1:36:25] to help patients
[1:36:26] with acute care needs
[1:36:28] receive inpatient-level
[1:36:29] care at home,
[1:36:31] improving outcomes
[1:36:32] and freeing up
[1:36:33] sparse hospital beds.
[1:36:35] State Medicaid agencies
[1:36:36] should be supporting
[1:36:37] these programs,
[1:36:39] but instead,
[1:36:39] they're being forced
[1:36:40] to spend their time
[1:36:41] and money complying
[1:36:43] with new federal mandates
[1:36:44] that will result
[1:36:45] in fewer people
[1:36:46] receiving health care.
[1:36:48] Mr. Bassieri,
[1:36:49] last year,
[1:36:50] New York State Comptroller
[1:36:51] Dean Apoli stated
[1:36:53] that the total cost
[1:36:54] of the Republicans'
[1:36:55] Big Ugly Bill
[1:36:56] to New York State
[1:36:57] would be $13 billion
[1:36:58] annually,
[1:37:00] including the administrative
[1:37:01] cost of implementation.
[1:37:03] The Medical Society
[1:37:04] of New York projected
[1:37:05] that the bill
[1:37:06] will increase
[1:37:06] administrative costs
[1:37:08] to the state
[1:37:09] by at least 20%.
[1:37:11] Is it fair to say
[1:37:12] that the administrative burdens
[1:37:14] of implementing HR1
[1:37:16] uses time and resources
[1:37:17] that could otherwise be used
[1:37:19] to deliver health care
[1:37:20] and fight fraud?
[1:37:23] Thank you
[1:37:23] for the question,
[1:37:24] Congresswoman.
[1:37:26] First and foremost,
[1:37:28] when we are overseeing
[1:37:29] the Medicaid program,
[1:37:30] we do take compliance
[1:37:32] and implementation
[1:37:34] of federal legislation
[1:37:35] very seriously,
[1:37:36] and as part
[1:37:38] of the passage of HR1,
[1:37:39] we are committed
[1:37:40] to doing that
[1:37:41] in an efficient
[1:37:42] and time-effective way.
[1:37:43] You are correct
[1:37:45] that the administrative cost
[1:37:47] associated
[1:37:48] with that implementation
[1:37:48] is significant
[1:37:50] as the largest
[1:37:51] administrative cost
[1:37:53] the state has encouraged
[1:37:54] the implementation
[1:37:55] of the ACA.
[1:37:57] But I don't necessarily,
[1:37:59] can't really speak
[1:38:00] to whether we would be
[1:38:02] using our time differently
[1:38:04] or elsewhere.
[1:38:05] I think we are very,
[1:38:07] very committed to...
[1:38:08] Well, what resources
[1:38:08] has your state had
[1:38:09] to deploy to ensure
[1:38:11] that Medicaid beneficiaries
[1:38:12] aren't thrown off their care
[1:38:14] because of HR1?
[1:38:16] We have had to incur
[1:38:18] a range of costs,
[1:38:19] both from a media,
[1:38:20] marketing, outreach,
[1:38:21] just informing people
[1:38:23] of the changes.
[1:38:23] We've been implementing
[1:38:25] a new eligibility
[1:38:26] and enrollment systems
[1:38:27] so that the process
[1:38:29] for consumers
[1:38:30] and providers
[1:38:30] or their caregivers
[1:38:32] is simple
[1:38:33] and transparent.
[1:38:34] And then we've been
[1:38:35] augmenting our county staff.
[1:38:37] I appreciate all that,
[1:38:38] but resources are not infinite,
[1:38:40] which is why
[1:38:41] I asked the question.
[1:38:42] I think Democrats warned
[1:38:43] that the red tape requirements
[1:38:45] in the Big Ugly Bill
[1:38:46] will divert millions
[1:38:48] of dollars
[1:38:48] from health care
[1:38:49] to administrative overhead.
[1:38:51] Mr. Chair,
[1:38:52] I'd like to submit
[1:38:52] a document for the record.
[1:38:56] Thank you.
[1:38:57] Last year,
[1:38:57] the GAO published
[1:38:58] a report investigating
[1:38:59] Georgia's Medicaid
[1:39:00] red tape requirements program.
[1:39:02] They found that
[1:39:03] since Georgia first received
[1:39:04] federal approval
[1:39:05] to implement its Medicaid
[1:39:07] red tape requirements,
[1:39:08] nearly 70% of all spending
[1:39:10] in that program
[1:39:11] has gone to administrative costs
[1:39:13] rather than to health care.
[1:39:15] And 88% of those
[1:39:17] administrative costs
[1:39:18] were paid
[1:39:18] by federal taxpayers.
[1:39:20] Dr. Connolly,
[1:39:21] last August,
[1:39:22] Minnesota's Department
[1:39:23] of Human Services
[1:39:25] shared that new requirements
[1:39:26] from the Big Ugly Bill
[1:39:27] could potentially increase
[1:39:29] state, local,
[1:39:30] and tribal administrative spending
[1:39:31] by $165 million annually.
[1:39:34] What do patients lose
[1:39:36] when federal Medicaid dollars
[1:39:37] are diverted
[1:39:38] from health care
[1:39:38] to setting up
[1:39:39] new administrative requirements?
[1:39:43] So I think there are...
[1:39:44] Thank you for the question,
[1:39:45] Representative Tran.
[1:39:46] I think there are
[1:39:46] two main considerations
[1:39:48] here on worries.
[1:39:49] Number one is,
[1:39:49] of course,
[1:39:49] the people who would lose coverage
[1:39:51] because of the new requirements.
[1:39:52] That is, of course,
[1:39:53] the principal concern
[1:39:54] that we have
[1:39:54] and that we've talked about
[1:39:56] in Minnesota.
[1:39:57] And the second, of course,
[1:39:58] is that we,
[1:39:59] as I stated earlier,
[1:40:00] have a structural budget deficit
[1:40:01] that we have to solve for.
[1:40:03] And so when additional requirements
[1:40:05] are placed on the state
[1:40:06] to administer
[1:40:07] that piece of the program
[1:40:09] or that piece
[1:40:09] of the federal legislation,
[1:40:10] that does, of course,
[1:40:11] require resources
[1:40:12] from the state,
[1:40:13] which we are already
[1:40:14] struggling to find.
[1:40:16] At a time when CMS
[1:40:17] is adding insult to injury,
[1:40:18] deferring $350 million
[1:40:20] in Medicaid payments
[1:40:22] to Minnesota.
[1:40:24] Look, Republican policies
[1:40:25] are increasing
[1:40:26] Medicaid administrative costs
[1:40:27] to states,
[1:40:28] leaving fewer resources
[1:40:29] for care,
[1:40:30] reducing access for patients,
[1:40:32] and kicking people
[1:40:32] off their coverage.
[1:40:34] And CMS is piling on
[1:40:35] by threatening funding
[1:40:36] and issuing endless requests
[1:40:39] to states
[1:40:39] that did not support
[1:40:40] the president.
[1:40:41] Sadly,
[1:40:42] it's patients and families
[1:40:43] across the country
[1:40:44] who will have to bear
[1:40:45] the consequence.
[1:40:46] It doesn't have to be
[1:40:47] this way, Mr. Chair.
[1:40:48] We can target waste,
[1:40:50] fraud, and abuse
[1:40:50] in our health care system.
[1:40:51] We all want to do that.
[1:40:52] But we have to do it
[1:40:53] in a way that doesn't
[1:40:54] threaten the care
[1:40:55] that the Americans
[1:40:56] desperately need.
[1:40:57] Thank you.
[1:40:57] I yield back.
[1:40:58] The gentlelady yields.
[1:41:00] The chair now recognizes
[1:41:01] the gentlewoman
[1:41:02] from Tennessee,
[1:41:02] Dr. Harshberger,
[1:41:03] for her five minutes
[1:41:04] of questioning.
[1:41:06] Thank you, Mr. Chairman,
[1:41:06] and thank you to the witnesses
[1:41:07] for being here today.
[1:41:09] I'm going to start
[1:41:10] with Mr. Connell
[1:41:11] and go down the line,
[1:41:12] and if you could be brief,
[1:41:13] it'd be awesome.
[1:41:14] When your agency receives
[1:41:16] reports of suspected fraud
[1:41:18] or comes across
[1:41:19] suspicious behavior,
[1:41:21] what's your preliminary
[1:41:22] investigation process entail?
[1:41:24] Start with you, sir.
[1:41:25] There's an intake process.
[1:41:26] If the evidence meets
[1:41:28] a certain threshold,
[1:41:29] then it's considered a case.
[1:41:30] The case is reviewed.
[1:41:31] If there's credible evidence
[1:41:32] of fraud,
[1:41:33] then it is reviewed
[1:41:34] to both the Attorney General's
[1:41:35] Office, the Medicaid
[1:41:36] Fraud Control Unit,
[1:41:37] as well as, in many cases,
[1:41:39] the U.S. Attorney's Office.
[1:41:40] Okay.
[1:41:41] Yes, sir.
[1:41:42] Thank you, Representative.
[1:41:43] We receive referrals
[1:41:45] and complaints
[1:41:46] from a variety of sources,
[1:41:48] including plans,
[1:41:49] providers, members,
[1:41:50] and internal referrals
[1:41:51] from data analytics.
[1:41:53] When we receive a complaint,
[1:41:54] we review it
[1:41:55] across a number
[1:41:55] of different criteria,
[1:41:57] including comprehensiveness
[1:41:58] of information,
[1:41:59] credibility, impact, etc.
[1:42:01] We then place
[1:42:02] these complaints
[1:42:03] in a risk queue
[1:42:04] based on prioritization.
[1:42:06] And then,
[1:42:06] as warranted,
[1:42:08] investigations are open
[1:42:09] through a multidisciplinary
[1:42:10] investigation process
[1:42:11] with financial auditors,
[1:42:13] sworn peace officers,
[1:42:15] investigators,
[1:42:16] data scientists,
[1:42:16] and clinicians
[1:42:17] to develop a comprehensive,
[1:42:19] credible allegation
[1:42:20] of fraud
[1:42:21] that is referred
[1:42:21] to the California
[1:42:22] Department of Justice.
[1:42:23] All right.
[1:42:24] Thanks.
[1:42:26] Thank you for the question.
[1:42:27] Similar to what you've heard,
[1:42:28] we have an intake process.
[1:42:30] What we do in New York
[1:42:32] is my office,
[1:42:33] who is primarily responsible
[1:42:34] for attempting to prevent.
[1:42:36] We'll do an investigation.
[1:42:37] We then work
[1:42:39] with our Office
[1:42:40] of Medicaid Inspector General
[1:42:41] who can make
[1:42:42] that credible allegation
[1:42:43] a fraud.
[1:42:44] And then,
[1:42:45] depending on the outcome
[1:42:45] of that,
[1:42:46] we will take
[1:42:47] payment sanction routes
[1:42:49] or we will be referring
[1:42:50] it to federal law enforcement.
[1:42:52] Okay.
[1:42:52] Yes, sir.
[1:42:53] Next.
[1:42:54] Congressman,
[1:42:55] similar to whether
[1:42:55] we have an intake process,
[1:42:57] those are reviewed
[1:42:58] by a multidisciplinary team
[1:43:00] that includes people
[1:43:00] from our department
[1:43:02] as well as our Attorney General
[1:43:03] and the Fuku unit.
[1:43:04] Those are reviewed
[1:43:05] and then referred
[1:43:05] to appropriate law enforcement
[1:43:07] as needed
[1:43:08] for additional investigation.
[1:43:09] Yes, sir.
[1:43:09] So they're all about the same.
[1:43:11] At what point
[1:43:12] is the case referred
[1:43:13] to the Medicaid
[1:43:13] Fraud Control Unit?
[1:43:18] So in Minnesota,
[1:43:19] thank you for the question,
[1:43:20] we refer to the Medicaid
[1:43:22] Fraud Control Unit
[1:43:23] when the case reaches
[1:43:24] the threshold
[1:43:25] of a credible allegation
[1:43:26] of fraud.
[1:43:26] Okay.
[1:43:27] It's the same for you?
[1:43:29] Yes, Representative.
[1:43:30] Okay.
[1:43:31] Same thing.
[1:43:32] Same.
[1:43:35] And I'll ask all of you
[1:43:36] the same,
[1:43:37] this question.
[1:43:38] On average,
[1:43:39] how long does it take
[1:43:40] your state
[1:43:40] to move from identifying
[1:43:42] a credible fraud allegation
[1:43:43] to payment suspensions?
[1:43:45] And if there is a delay,
[1:43:48] what's the primary cause
[1:43:49] of that delay
[1:43:49] in any timeline?
[1:43:52] Thank you,
[1:43:53] Representative Harshberger.
[1:43:54] So in Minnesota,
[1:43:55] that occurs
[1:43:55] as promptly as possible,
[1:43:56] sometimes within days
[1:43:58] or weeks,
[1:43:58] depending on how quickly
[1:43:59] we can implement that.
[1:44:00] But we do that now
[1:44:01] very, very immediately.
[1:44:03] Okay.
[1:44:05] Sir?
[1:44:06] So it is
[1:44:07] dependent on the circumstances.
[1:44:09] California is one
[1:44:10] of the few states
[1:44:11] with the ability
[1:44:11] to stop payments
[1:44:13] even before
[1:44:14] the level
[1:44:15] of a credible
[1:44:15] allegation of fraud
[1:44:16] is reached,
[1:44:17] at which point
[1:44:18] payment suspensions
[1:44:18] are typically put
[1:44:19] into place.
[1:44:20] At some points in time,
[1:44:22] however,
[1:44:22] the Medicaid fraud
[1:44:23] control unit
[1:44:24] will request
[1:44:25] good cause exemptions
[1:44:26] so that they can
[1:44:27] continue to build
[1:44:28] their criminal
[1:44:29] or civil prosecution
[1:44:30] case without interfering.
[1:44:32] So that could be a factor.
[1:44:33] Yes, sir?
[1:44:35] Thank you for the question.
[1:44:37] It is dependent
[1:44:38] on both the type
[1:44:39] of allegation fraud
[1:44:41] but also to the extent
[1:44:44] it goes beyond Medicaid
[1:44:46] or just the public programs.
[1:44:48] It does vary
[1:44:49] and it can be relatively quick
[1:44:52] depending on how credible
[1:44:53] that allegation is.
[1:44:55] Weeks?
[1:44:56] Maybe a couple of months
[1:44:58] but it can take a long time
[1:44:59] as well.
[1:45:00] It's very variable
[1:45:01] depending on the issue.
[1:45:03] Congresswoman,
[1:45:04] similar to theirs,
[1:45:05] ours varies
[1:45:06] depending on the allegation
[1:45:07] and depending on our
[1:45:08] de-confliction
[1:45:09] with our law enforcement
[1:45:10] partners to ensure
[1:45:11] we are not conflicting
[1:45:13] with their investigation.
[1:45:14] Okay.
[1:45:15] When a provider is allowed
[1:45:17] to continue receiving
[1:45:18] payments under a good cause
[1:45:19] as you mentioned,
[1:45:21] determination during
[1:45:22] an investigation,
[1:45:23] what's the average duration
[1:45:24] of continued payment
[1:45:26] before a final suspension
[1:45:27] or a corrective action
[1:45:28] is implemented?
[1:45:30] Anybody can answer that.
[1:45:32] Start with you,
[1:45:33] Mr. Connell.
[1:45:35] So if I understand
[1:45:36] the question,
[1:45:37] you're asking
[1:45:37] what is the duration
[1:45:38] of time between
[1:45:39] those two things happening?
[1:45:40] Yeah,
[1:45:40] if you suspend,
[1:45:41] I mean,
[1:45:41] if you're receiving payments
[1:45:43] under a good cause
[1:45:44] determination.
[1:45:46] I think I'd have to take
[1:45:47] that back and get details
[1:45:48] for you.
[1:45:51] It varies,
[1:45:52] but we have been engaging
[1:45:53] our Medicaid fraud
[1:45:54] control unit
[1:45:55] to reduce the number
[1:45:58] of good cause exemptions
[1:45:59] that they request.
[1:46:00] Okay.
[1:46:02] It varies,
[1:46:03] and it's very important
[1:46:04] for us to prioritize
[1:46:05] continuity of care
[1:46:06] or ensure that access
[1:46:07] can be provided
[1:46:08] if an instance
[1:46:09] like that is reached.
[1:46:11] It varies,
[1:46:12] however,
[1:46:12] we have made recent efforts
[1:46:13] to improve that.
[1:46:15] Well,
[1:46:15] that's all I got to,
[1:46:16] Mr. Chairman,
[1:46:17] so my time's up
[1:46:18] and I'll yield back.
[1:46:19] The general lady yields.
[1:46:20] The chair now recognizes
[1:46:21] Ms. Fletcher
[1:46:22] for her five minutes
[1:46:23] of questioning.
[1:46:25] Thank you,
[1:46:26] Chairman Joyce,
[1:46:26] and thank you
[1:46:27] to our witnesses
[1:46:28] for your time
[1:46:30] here today.
[1:46:32] Fraud is a genuine
[1:46:33] problem
[1:46:34] in federal programs,
[1:46:36] including in Medicaid.
[1:46:37] that is why Congress
[1:46:40] and many past administrations
[1:46:42] have worked
[1:46:43] to pass laws
[1:46:44] and develop procedures
[1:46:46] to investigate,
[1:46:48] document,
[1:46:49] and remedy it,
[1:46:50] and federal law
[1:46:52] has well-developed procedures
[1:46:54] for how agencies
[1:46:56] must address fraud,
[1:46:58] and that includes requirements
[1:47:01] that agencies identify
[1:47:02] a credible basis
[1:47:03] for suspecting fraud
[1:47:05] before pausing funds,
[1:47:07] provide notice
[1:47:07] and an opportunity
[1:47:08] to be heard,
[1:47:10] impose penalties
[1:47:11] that are proportionate
[1:47:12] to their findings.
[1:47:13] They are tools
[1:47:15] that many administrations
[1:47:17] have used
[1:47:18] of both parties
[1:47:20] for many,
[1:47:21] many years.
[1:47:22] In fact,
[1:47:23] under President George W. Bush,
[1:47:24] there was a Medicare fraud
[1:47:26] strike force
[1:47:26] that charged thousands
[1:47:28] of defendants
[1:47:29] and recovered tens
[1:47:30] of billions of dollars
[1:47:31] doing it the right way,
[1:47:33] and that's the key here.
[1:47:35] This issue is not new,
[1:47:37] but this is the third
[1:47:39] subcommittee hearing
[1:47:40] that we have had
[1:47:41] in this Congress
[1:47:43] on Medicaid fraud
[1:47:45] in state programs,
[1:47:47] and we have not had hearings
[1:47:48] on so many other areas
[1:47:51] in the government
[1:47:53] where fraud is not only possible,
[1:47:56] but appears to be happening
[1:47:58] right in front of our eyes.
[1:48:01] So one of them,
[1:48:02] I think,
[1:48:04] appears to be
[1:48:05] the Trump administration's claim
[1:48:07] of waste, fraud,
[1:48:09] and abuse indiscriminately
[1:48:11] to cut funds
[1:48:13] from states
[1:48:15] and from programs
[1:48:17] that it doesn't like
[1:48:19] or it doesn't understand.
[1:48:22] We don't need to look
[1:48:23] a lot further
[1:48:24] than Doja's cuts
[1:48:25] to the screwworm research programs
[1:48:27] to see that
[1:48:29] when they don't understand
[1:48:30] what the government's doing.
[1:48:32] They would cut it.
[1:48:34] Or cutting funds
[1:48:37] and using these claims
[1:48:38] because it appears to them
[1:48:40] that it benefits
[1:48:42] their perceived political opponents.
[1:48:46] That is what is going on here.
[1:48:49] And this Congress
[1:48:50] has been a willing partner
[1:48:52] in that effort,
[1:48:55] repeating waste, fraud,
[1:48:56] and abuse ad nauseam
[1:48:58] to justify cutting
[1:49:00] health care funding
[1:49:02] and food assistance,
[1:49:04] taking care away
[1:49:06] from people who are sick
[1:49:08] and taking food away
[1:49:10] from people who are hungry.
[1:49:14] And, you know,
[1:49:14] the purported concerns
[1:49:16] about waste, fraud,
[1:49:18] and abuse
[1:49:19] that we keep hearing
[1:49:20] are really belied
[1:49:21] by the facts
[1:49:22] of the last year and a half.
[1:49:24] President Trump
[1:49:26] has pardoned,
[1:49:27] according to the New York Times,
[1:49:31] at least 70 allies,
[1:49:34] donors,
[1:49:35] and other people
[1:49:36] who have been convicted
[1:49:38] of fraud,
[1:49:40] including convicted
[1:49:41] of defrauding
[1:49:42] the United States government
[1:49:44] through Medicaid fraud.
[1:49:46] The president
[1:49:47] is pardoning them.
[1:49:49] People who defrauded
[1:49:52] the United States
[1:49:53] and took away
[1:49:54] the very services
[1:49:55] that we've been hearing about
[1:49:56] throughout this hearing
[1:49:58] from the people
[1:49:59] who were gathered
[1:50:00] in this room
[1:50:00] who deserve to receive them.
[1:50:02] The president
[1:50:03] is pardoning those people.
[1:50:05] And we also see
[1:50:07] not only has that increased
[1:50:11] since the first term,
[1:50:12] there have been
[1:50:13] nearly three dozen
[1:50:14] pardons and commutations
[1:50:16] of people
[1:50:17] who've been accused of fraud.
[1:50:19] And, of course,
[1:50:21] this administration
[1:50:22] has dismantled
[1:50:23] the agencies
[1:50:26] and the organizations
[1:50:28] that are designed
[1:50:29] and that have been created
[1:50:30] to investigate fraud
[1:50:32] and to root it out.
[1:50:34] For example,
[1:50:34] the 20 inspectors general
[1:50:36] that President Trump
[1:50:37] fired or demoted
[1:50:39] that identified
[1:50:40] more than $50 billion
[1:50:41] in waste and abuse
[1:50:43] in the 2024 fiscal year.
[1:50:46] These things don't add up
[1:50:48] with the stated purpose
[1:50:49] of rooting out
[1:50:50] waste, fraud, and abuse.
[1:50:53] Don't be fooled
[1:50:55] about what is going on
[1:50:56] in this administration
[1:50:57] and what is going on
[1:50:58] in this Congress.
[1:51:00] We know that hundreds
[1:51:02] of billions of dollars
[1:51:03] in funding for people
[1:51:06] across this country
[1:51:07] flows from the federal
[1:51:08] government to the states
[1:51:09] through programs
[1:51:10] like Medicaid and SNAP.
[1:51:13] And we know
[1:51:14] that by invoking fraud
[1:51:16] as a grounds
[1:51:17] for freezing states' funds,
[1:51:20] this administration
[1:51:21] is extracting its retribution
[1:51:24] against its perceived enemies.
[1:51:26] Do not be fooled by it
[1:51:28] and don't be used by it
[1:51:30] and don't look away
[1:51:32] from the other
[1:51:33] waste, fraud, and abuse
[1:51:34] that is happening
[1:51:35] before our eyes.
[1:51:36] Thank you,
[1:51:37] and I yield back.
[1:51:38] General Lady Yields,
[1:51:39] the chair now recognizes
[1:51:40] the gentleman from Ohio,
[1:51:41] Mr. Rulli,
[1:51:42] for his five minutes
[1:51:43] of questioning.
[1:51:44] Well, I appreciate that,
[1:51:45] Chairman,
[1:51:45] and I think there is
[1:51:47] a lot of fraud
[1:51:48] in these states
[1:51:48] at local levels,
[1:51:50] and my attention
[1:51:51] goes to Mr. Partika
[1:51:53] from Ohio.
[1:51:55] I also want to thank
[1:51:55] Keith Faber from Ohio
[1:51:56] for actively investigating
[1:51:58] discrepancies
[1:51:59] that we found implemented
[1:52:01] in the Medicaid expansion
[1:52:02] program of the state of Ohio.
[1:52:05] HCBS services
[1:52:07] allow seniors
[1:52:07] in the state of Ohio
[1:52:08] with disabilities
[1:52:09] to receive care at home
[1:52:11] rather than in institution.
[1:52:13] This is, at the core,
[1:52:15] a beautiful thing
[1:52:16] where we could have
[1:52:16] a family member
[1:52:17] stay at home
[1:52:18] and take care
[1:52:19] of their loved ones,
[1:52:19] which is everyone's
[1:52:20] ideal situation.
[1:52:22] The problem
[1:52:23] that we find out
[1:52:24] is sometimes
[1:52:24] you have three
[1:52:25] or four family members
[1:52:26] that are all
[1:52:27] staying at home,
[1:52:28] and the family's
[1:52:29] bringing $150,000
[1:52:30] or $200,000
[1:52:30] of money to that family
[1:52:32] by them all staying
[1:52:33] at home
[1:52:33] and doing nothing.
[1:52:35] The program
[1:52:35] wasn't built for that,
[1:52:36] and that's not
[1:52:37] what it was supposed
[1:52:37] to be about.
[1:52:39] However, fraud
[1:52:40] diverts resources
[1:52:40] away from patients
[1:52:41] who truly need that care.
[1:52:43] And in Ohio,
[1:52:44] when I was a state senator,
[1:52:46] Ohio's fourth in the country
[1:52:47] for Medicaid expansion.
[1:52:49] We have a $93 billion budget
[1:52:51] in the state of Ohio,
[1:52:52] which is every bipartisan,
[1:52:54] which is everybody
[1:52:54] by two years
[1:52:56] that it runs
[1:52:56] on $93 billion,
[1:52:58] and we're using
[1:52:58] almost half of that
[1:52:59] for Medicaid expansion.
[1:53:01] In Ohio,
[1:53:01] we correct our wrongs.
[1:53:03] I saw Governor Waltz,
[1:53:04] whose state
[1:53:05] is the number one
[1:53:06] worst fraud
[1:53:07] in the entire country,
[1:53:09] gallivanting
[1:53:09] all over the country,
[1:53:11] trying to attack Republicans.
[1:53:12] When he was at home,
[1:53:14] he should have been
[1:53:14] at home correcting this fraud.
[1:53:16] So my question
[1:53:17] to you, director,
[1:53:18] is I know
[1:53:19] that your administration
[1:53:20] has already been working.
[1:53:21] Can you go through
[1:53:22] some of the fraud
[1:53:22] that you already discovered?
[1:53:24] And more importantly
[1:53:24] than that,
[1:53:25] can you go through
[1:53:26] the fraud
[1:53:26] that you think
[1:53:26] you might find?
[1:53:30] Congressman,
[1:53:31] thank you for the question.
[1:53:32] And we share
[1:53:33] at Medicaid
[1:53:34] your sentiment
[1:53:34] towards the meaningful
[1:53:35] intent of many
[1:53:37] of these programs,
[1:53:38] which is why
[1:53:38] we find anyone
[1:53:39] defrauding them,
[1:53:41] insulting,
[1:53:42] and needing addressed
[1:53:43] so that we can provide
[1:53:44] that long-term stability.
[1:53:45] As we talked about
[1:53:46] in the home health
[1:53:47] safety space,
[1:53:48] we've identified
[1:53:50] abnormal trends
[1:53:51] in different parts
[1:53:52] of our state,
[1:53:52] abnormal billing patterns
[1:53:53] that we are now
[1:53:54] working to address.
[1:53:56] We, as I've identified
[1:53:57] and has been in the news,
[1:53:58] the $42 million finding
[1:54:00] on the behavioral health services
[1:54:02] providing our community
[1:54:03] that we have been working
[1:54:04] on making policy changes,
[1:54:05] including prior authorizations,
[1:54:07] reviewing our enrollment process,
[1:54:08] and identifying high-risk providers
[1:54:10] in each of those areas.
[1:54:13] The critical challenge
[1:54:14] as we do this work
[1:54:15] moving forward
[1:54:16] is making sure
[1:54:16] we are doing it
[1:54:17] in a way that is responsible
[1:54:18] and does not punish
[1:54:19] the hardworking providers
[1:54:21] that are doing it
[1:54:22] the right way
[1:54:22] each and every day
[1:54:23] so we can fulfill
[1:54:24] that commitment
[1:54:24] to provide those services
[1:54:26] to those that are truly
[1:54:28] intended and needing that care.
[1:54:30] What was exciting
[1:54:31] for me, Director,
[1:54:32] is when I realized
[1:54:33] that we had
[1:54:34] the Attorney General
[1:54:35] and we had the Auditor
[1:54:36] working with your office
[1:54:37] because you know what?
[1:54:39] In life,
[1:54:39] sometimes we're not perfect
[1:54:40] and the wonderful story
[1:54:41] about America
[1:54:42] is like,
[1:54:43] and you look at our history,
[1:54:44] we correct our wrongs
[1:54:45] like we do in Ohio.
[1:54:46] So we're not all full
[1:54:48] of ourselves
[1:54:48] that say that we're perfect
[1:54:49] in the state of Ohio.
[1:54:50] We know that we're flawed
[1:54:52] but I like the idea
[1:54:53] that the three branches
[1:54:55] over there,
[1:54:55] you've got the Attorney General's Office,
[1:54:57] you've got the Ohio Auditor
[1:54:58] and then you have you
[1:54:59] that are all working together
[1:55:01] to make it better.
[1:55:02] When you're fourth in the country
[1:55:04] for Medicaid expansion,
[1:55:05] we want to make sure
[1:55:05] that our people
[1:55:06] have their services.
[1:55:08] Now,
[1:55:09] in the next year or two,
[1:55:10] how do you think
[1:55:11] this partnership
[1:55:12] that you have
[1:55:13] with the Attorney General's Office
[1:55:14] and the Auditor's Office
[1:55:16] is going to look like?
[1:55:17] Do you think
[1:55:17] we're going to really be able
[1:55:18] to get down into the nitty-gritty
[1:55:20] and even get a lot more fraud
[1:55:21] in the next six months,
[1:55:23] the next two years?
[1:55:24] How do you think
[1:55:24] this is all going to play out
[1:55:26] with that union
[1:55:26] of your three different branches
[1:55:28] helping each other?
[1:55:31] Congressman,
[1:55:31] as you stated,
[1:55:32] that partnership
[1:55:33] over the years
[1:55:34] spanning multiple administrations
[1:55:35] has been incredibly valuable.
[1:55:37] Many of the findings
[1:55:37] the Auditor has had
[1:55:38] have directly correlated
[1:55:40] improvements to the Medicaid program.
[1:55:42] I expect that to continue.
[1:55:44] The work with our Attorney General
[1:55:45] and our new Attorney General,
[1:55:46] Andy Wilson,
[1:55:47] I expect to be incredibly powerful
[1:55:49] as the teams work together.
[1:55:51] The newfound partnership
[1:55:53] of not just looking
[1:55:53] at each individual case
[1:55:55] and where we're identifying trends
[1:55:56] to identify new investigations,
[1:55:58] but bringing that back
[1:55:59] to our team
[1:56:00] and saying,
[1:56:00] here are potential risks
[1:56:01] from a policy standpoint
[1:56:02] in the administration
[1:56:03] of that program.
[1:56:04] I'm incredibly hopeful
[1:56:05] that we continue
[1:56:06] to make improvements
[1:56:06] moving forward,
[1:56:08] much thanks to that expertise
[1:56:09] that those multiple teams bring.
[1:56:11] I really appreciate it.
[1:56:13] It gets exciting thinking
[1:56:14] that when we discover
[1:56:15] something like that
[1:56:16] and just saying
[1:56:16] how horrific it is,
[1:56:18] when we can look at the future
[1:56:19] and preserve
[1:56:19] these wonderful institutions
[1:56:21] like when you have a Medicaid
[1:56:22] or Medicare
[1:56:22] or even Social Security,
[1:56:24] if we're able to find this fraud,
[1:56:25] we will preserve these
[1:56:26] so they can last for generations
[1:56:27] for our grandkids
[1:56:28] and our great-grandkids.
[1:56:30] I appreciate all the work
[1:56:31] you do for the fine state of Ohio.
[1:56:32] And with that,
[1:56:33] I yield my time, Chairman.
[1:56:34] The gentleman yields.
[1:56:35] The chair now recognizes
[1:56:36] the gentleman from California,
[1:56:38] Mr. Mullen,
[1:56:38] for his five minutes of questioning.
[1:56:40] Thank you, Mr. Chairman.
[1:56:42] Thank you to the witnesses
[1:56:42] for your testimony today.
[1:56:45] The Medicaid program
[1:56:45] embodies a deep
[1:56:46] and long-standing partnership
[1:56:48] between the federal government
[1:56:49] and the states.
[1:56:50] Every individual
[1:56:51] has a right to health care,
[1:56:52] so thank you for working
[1:56:53] to ensure the most vulnerable
[1:56:55] in our communities
[1:56:56] can also benefit from that right.
[1:56:59] This is the third Medicaid fraud hearing
[1:57:01] the Republican majority
[1:57:02] has held this year,
[1:57:03] despite their presenting zero,
[1:57:05] I repeat,
[1:57:06] zero evidence
[1:57:07] of widespread fraud.
[1:57:09] At the same time,
[1:57:10] they have let the Trump administration
[1:57:11] fire inspectors general
[1:57:13] and others actually doing the work
[1:57:14] to address the narrow cases
[1:57:16] where fraud does exist.
[1:57:18] President Trump
[1:57:19] has been using the guise
[1:57:20] of investigating fraud
[1:57:22] as a smokescreen
[1:57:23] to punish the states
[1:57:25] he does not politically agree with.
[1:57:27] This administration
[1:57:28] is putting the health coverage
[1:57:29] of millions at risk
[1:57:30] in states like California,
[1:57:32] all to score political points.
[1:57:35] While the majority
[1:57:35] is politicizing
[1:57:36] this vital health care program,
[1:57:38] hardworking public servants
[1:57:39] like Director Sadwith
[1:57:41] aren't focused on cheap headlines.
[1:57:43] He's working to ensure Californians
[1:57:45] have health care coverage
[1:57:46] and that public dollars
[1:57:47] are being spent responsibly
[1:57:49] as intended.
[1:57:50] So, Director Sadwith,
[1:57:51] you mentioned in your testimony
[1:57:52] that Medi-Cal
[1:57:53] goes above federal standards
[1:57:55] to screen providers
[1:57:56] before they gain access
[1:57:57] to the program.
[1:57:59] Can you please explain
[1:58:00] how California
[1:58:01] is exceeding
[1:58:02] federal requirements
[1:58:03] to prevent bad actors
[1:58:04] from ever gaining access
[1:58:05] to Medi-Cal?
[1:58:07] Thank you, Congressman.
[1:58:08] I'd be happy to.
[1:58:09] So, when providers
[1:58:11] initially screen,
[1:58:12] we collect and review information
[1:58:13] that CMS doesn't require.
[1:58:15] These include
[1:58:16] state-specific standards
[1:58:18] around established
[1:58:19] place of business.
[1:58:20] So, for every single
[1:58:21] provider site
[1:58:21] that enrolls,
[1:58:23] we look at leases,
[1:58:25] business licenses,
[1:58:27] general liability insurance,
[1:58:28] and so forth.
[1:58:29] We also require
[1:58:30] our managed care plans
[1:58:31] to conduct monthly screening
[1:58:33] against state
[1:58:34] and federal exclusionary
[1:58:35] lists and databases
[1:58:37] just to, you know,
[1:58:39] further ensure
[1:58:40] there are no bad actors
[1:58:41] in our program.
[1:58:43] We also exceed requirements
[1:58:44] regarding how frequently
[1:58:46] we revalidate providers,
[1:58:48] and revalidating is,
[1:58:49] in effect,
[1:58:50] re-screening
[1:58:50] against all databases
[1:58:51] and checking
[1:58:52] to make sure
[1:58:53] that they're legitimate.
[1:58:54] Anytime a provider
[1:58:55] in California
[1:58:56] adds a new location,
[1:58:58] changes their address,
[1:58:59] or changes ownership,
[1:59:00] that triggers
[1:59:01] a full revalidation,
[1:59:02] which often happens
[1:59:03] more frequently
[1:59:03] than every five years
[1:59:04] as federally required.
[1:59:05] So, thank you
[1:59:07] for that explanation.
[1:59:08] Your testimony today
[1:59:09] is vital for us
[1:59:10] to parse between
[1:59:11] false claims
[1:59:11] about Medicaid
[1:59:12] and what is actually
[1:59:13] happening on the ground
[1:59:14] in my home state
[1:59:15] of California.
[1:59:16] The administration
[1:59:17] has been laser-focused
[1:59:18] on the IHSS program
[1:59:20] in Medi-Cal,
[1:59:21] which allows elderly
[1:59:21] and disabled individuals
[1:59:23] with long-term care needs
[1:59:24] to remain in the comfort
[1:59:26] of their homes.
[1:59:26] Based almost solely
[1:59:28] on growth in the program,
[1:59:29] the Trump administration
[1:59:30] recently deferred
[1:59:31] over $1 billion
[1:59:32] for that IHSS program.
[1:59:34] So, Director Sadwith,
[1:59:35] what are the reasons
[1:59:36] for IHSS program's
[1:59:38] growth and cost increases
[1:59:40] that you have explained
[1:59:41] to CMS,
[1:59:42] and what are the impacts
[1:59:44] of this billion-dollar
[1:59:45] deferral on Medi-Cal,
[1:59:46] and how are you working
[1:59:47] to ensure that beneficiaries
[1:59:48] still have access
[1:59:49] to those services?
[1:59:51] Thank you, Congressman.
[1:59:53] The intentional investment
[1:59:55] in our in-home
[1:59:57] supportive services program
[1:59:58] reflects a long-standing
[2:00:00] partnership
[2:00:01] with the federal government,
[2:00:03] including Congress
[2:00:04] and CMS,
[2:00:05] who have consistently,
[2:00:06] over the past quarter century,
[2:00:08] promoted and expanded
[2:00:09] the use of home
[2:00:10] and community-based services.
[2:00:12] That is because these
[2:00:13] are the services
[2:00:13] that are best for individuals
[2:00:15] who depend on them.
[2:00:16] It's also better
[2:00:16] for taxpayers.
[2:00:17] We know these are cost-effective.
[2:00:20] CMS asked about our growth.
[2:00:22] We explained that,
[2:00:23] you know,
[2:00:24] several years ago,
[2:00:25] the California State Auditor,
[2:00:26] an independent fiscal watchdog,
[2:00:29] reviewed our IHSS program,
[2:00:31] and while they found
[2:00:32] no program integrity concerns,
[2:00:34] the audit did have
[2:00:35] one recommendation.
[2:00:36] They recommended
[2:00:37] we increase reimbursement rates
[2:00:39] so we can expand
[2:00:40] the IHSS workforce
[2:00:41] to meet the needs
[2:00:43] of California's aging
[2:00:44] and growing population.
[2:00:46] So we did that.
[2:00:47] We increased payment.
[2:00:48] We increased caseloads
[2:00:49] so more people
[2:00:50] can get these services,
[2:00:51] and as a result,
[2:00:52] the program grew.
[2:00:53] This is a concerning deferral,
[2:00:56] and we are working steadfastly
[2:00:57] with CMS
[2:00:58] to respond to all their questions,
[2:01:00] provide all the information
[2:01:01] they need
[2:01:02] so they can release the deferral
[2:01:03] and recipients can get
[2:01:05] the care they need.
[2:01:08] So let me just conclude
[2:01:10] that Medicaid is a lifeline
[2:01:12] for millions of Americans.
[2:01:14] Rather than using California
[2:01:15] as a political punching bag,
[2:01:17] we need to be focusing
[2:01:17] on our efforts
[2:01:19] to strengthen
[2:01:20] this important
[2:01:21] federal-state partnership.
[2:01:23] And with that,
[2:01:23] Mr. Chair,
[2:01:24] I yield back.
[2:01:24] The gentleman yields.
[2:01:25] The chair now recognizes
[2:01:27] the gentleman from Texas,
[2:01:28] Mr. Weber,
[2:01:29] for his five minutes
[2:01:30] of questioning.
[2:01:30] Thank you, Mr. Chairman.
[2:01:31] I'm late because of
[2:01:32] science, space, and technology.
[2:01:33] We had a markup
[2:01:34] they had to participate in.
[2:01:35] I walked in on a bunch
[2:01:36] of claims
[2:01:37] from one of our colleagues
[2:01:38] across the aisle there.
[2:01:40] Mr. Chairman,
[2:01:40] it's not that they're ignorant.
[2:01:42] It's just that so much
[2:01:43] of what they know ain't so.
[2:01:45] So let me go to you,
[2:01:46] Mr. Connolly.
[2:01:48] Thank you for your testimony.
[2:01:49] The level of fraud
[2:01:50] that has been unearthed
[2:01:51] in Minnesota's Medicaid program
[2:01:52] is alarming.
[2:01:54] In what ways
[2:01:55] is the Department
[2:01:55] of Human Services
[2:01:56] revising the state's
[2:01:57] previous Medicaid provider
[2:01:59] enrollment process
[2:02:00] for new providers
[2:02:02] in the 14 high-risk programs
[2:02:04] to improve provider screening
[2:02:05] going forward?
[2:02:08] Thank you,
[2:02:08] Representative Weber.
[2:02:09] And we agree
[2:02:10] the fraud that has occurred
[2:02:11] is unacceptable,
[2:02:12] and that's why we worked hard
[2:02:13] on provider enrollment
[2:02:14] and compliance.
[2:02:16] Directly to your question,
[2:02:17] we have designated
[2:02:18] 14 services as high-risk,
[2:02:21] 13 remaining,
[2:02:22] and part of that
[2:02:23] involves provider enrollment
[2:02:26] and compliance action
[2:02:27] that is escalated.
[2:02:28] So there's an unannounced
[2:02:30] site visit that could occur,
[2:02:32] that does occur, rather,
[2:02:33] in addition to a fingerprint
[2:02:34] background check
[2:02:35] and more frequent revalidations.
[2:02:38] And all of those providers
[2:02:39] have been revalidated
[2:02:40] within the past five months
[2:02:41] as well in partnership
[2:02:43] in completing
[2:02:44] that corrective action plan
[2:02:45] at the direction of CMS.
[2:02:47] So these are targets.
[2:02:49] These 14 services
[2:02:50] were targets for the fraudsters.
[2:02:52] Is that low-hanging fruit?
[2:02:54] Why do you think that is?
[2:02:56] Could you repeat
[2:02:56] the question one more time?
[2:02:57] These 14 services
[2:02:59] were targets for the fraudsters.
[2:03:01] Is that because
[2:03:02] low-hanging fruit?
[2:03:03] We're not a fruit?
[2:03:04] We're not paying enough attention?
[2:03:05] What do you think?
[2:03:06] Why do you think that is?
[2:03:07] Thank you for the question,
[2:03:08] Representative Weber.
[2:03:09] So I think it's for
[2:03:10] a variety of reasons,
[2:03:11] and we've demonstrated
[2:03:12] in our actions
[2:03:14] what we think those reasons were.
[2:03:15] So it starts with the design
[2:03:16] and the policy around the program.
[2:03:19] So are there different requirements
[2:03:20] that need to be escalated?
[2:03:22] New billing parameters, for example.
[2:03:24] We implemented
[2:03:25] enhanced prepayment review
[2:03:26] to vet claims
[2:03:27] before they go out to providers
[2:03:28] so we don't pay
[2:03:29] and then have to recover
[2:03:30] if there's fraud.
[2:03:31] We also do post-payment activity,
[2:03:34] often in the form of investigations.
[2:03:36] We have data analytics
[2:03:37] that also inform referrals
[2:03:38] to our inspector general
[2:03:39] for investigation.
[2:03:42] And then, of course,
[2:03:43] if those cases rise
[2:03:45] to the level
[2:03:46] of a credible allegation of fraud,
[2:03:47] we then refer promptly
[2:03:48] to federal and state law enforcement
[2:03:50] for further investigation
[2:03:51] and prosecution
[2:03:52] if they deem that necessary.
[2:03:53] Do you keep a list
[2:03:54] of all the fraudsters
[2:03:55] and their procedures
[2:03:56] so that you can recognize
[2:03:58] that going forward?
[2:03:59] Yes.
[2:03:59] As a part of our investigations,
[2:04:01] we have a list
[2:04:02] of all of the providers
[2:04:03] that have risen
[2:04:05] to the level
[2:04:05] of a credible allegation of fraud.
[2:04:07] And certainly,
[2:04:07] we're paying attention
[2:04:08] to any announcement of charges
[2:04:10] with respect to law enforcement.
[2:04:12] So, we do look
[2:04:14] at the behaviors
[2:04:15] and the different things
[2:04:16] that we found
[2:04:17] in terms of how they've built
[2:04:18] and behaved,
[2:04:19] and we do keep that intelligence.
[2:04:21] So, if there's any cracks
[2:04:22] in our walls,
[2:04:23] you're able to go back
[2:04:24] and fix those cracks.
[2:04:26] Yes, exactly.
[2:04:27] So, if there is a pattern
[2:04:28] or a concerning issue
[2:04:29] that we identify
[2:04:30] that does inform,
[2:04:32] perhaps,
[2:04:32] administrative changes
[2:04:33] in policy,
[2:04:34] we might also engage legislators
[2:04:36] to make changes
[2:04:36] to those programs,
[2:04:37] which we've done
[2:04:38] in the last two sessions
[2:04:39] as a good example.
[2:04:40] All right.
[2:04:40] Thank you for that,
[2:04:41] Mr. Sat.
[2:04:41] Is it Sadwith?
[2:04:42] Is that how that's said?
[2:04:44] Yes, sir.
[2:04:45] Sadwith.
[2:04:45] Okay.
[2:04:46] Have you had that name long?
[2:04:48] Excuse me, sir.
[2:04:49] I'm just messing with you.
[2:04:51] Your written testimony
[2:04:52] highlights that Medi-Cal
[2:04:54] has, quote,
[2:04:54] strong policies
[2:04:56] that are designed
[2:04:56] to prevent,
[2:04:57] identify,
[2:04:58] and block
[2:04:58] the fraud,
[2:04:59] waste,
[2:04:59] and abuse
[2:05:00] we were just talking about.
[2:05:01] Below this,
[2:05:02] your testimony cites
[2:05:03] that California's
[2:05:05] Medicaid Fraud Control Unit,
[2:05:07] MFCU,
[2:05:08] received 700 credible
[2:05:10] fraud allegations
[2:05:11] over the last five years,
[2:05:14] while fraudulent hospice
[2:05:16] billing in Los Angeles County
[2:05:18] alone is estimated
[2:05:20] at $3.5 billion
[2:05:22] with a B dollars.
[2:05:23] That accounts for 18%
[2:05:26] of all national hospice billing.
[2:05:31] Would you say
[2:05:31] California's MCFU
[2:05:33] was effective
[2:05:33] in preventing that abuse?
[2:05:35] Thank you for the question.
[2:05:37] And this is
[2:05:38] an incredibly important issue,
[2:05:40] and it underscores
[2:05:41] the need for collaboration,
[2:05:43] continued collaboration
[2:05:44] between states
[2:05:45] and the federal government.
[2:05:46] In California,
[2:05:47] the primary payer
[2:05:48] for hospice care
[2:05:49] is Medicare.
[2:05:51] In Medicaid,
[2:05:52] which the Medicaid
[2:05:53] Fraud Control Unit
[2:05:54] sort of prosecutes,
[2:05:56] we've referred
[2:05:57] over 300 credible
[2:05:59] allegations of fraud
[2:06:00] to the MFCU
[2:06:01] over the past five years
[2:06:02] for the purposes
[2:06:03] of investigating
[2:06:04] and cracking down
[2:06:05] on hospice fraud
[2:06:06] in the Medi-Cal program,
[2:06:08] the state program
[2:06:08] that I oversee.
[2:06:10] But that's why
[2:06:11] it's important
[2:06:12] to work in partnership
[2:06:12] with the federal government
[2:06:14] and CMS,
[2:06:15] which is responsible
[2:06:16] for oversight of Medicare.
[2:06:18] Yeah, but you said 300,
[2:06:19] and I cited 700.
[2:06:20] That's not even
[2:06:21] a 50% of success rate,
[2:06:23] is it?
[2:06:25] So we view
[2:06:25] the 300 referrals
[2:06:27] as a strong commitment
[2:06:28] to California's
[2:06:30] rooting out bad actors
[2:06:31] in our Medicaid program.
[2:06:33] And we,
[2:06:34] just like Medicare and CMS,
[2:06:36] we have experienced
[2:06:37] issues in hospice
[2:06:38] and have taken
[2:06:39] comprehensive steps
[2:06:40] to protect the program,
[2:06:42] protect the Medicaid program
[2:06:43] through new requirements
[2:06:45] and new safeguards
[2:06:46] and institute licensure moratoriums,
[2:06:49] institute new regulations.
[2:06:50] We've criminally charged
[2:06:51] over 100 individuals
[2:06:53] in the past few years.
[2:06:54] We've set up
[2:06:55] a statewide hospice task force.
[2:06:58] We've revoked
[2:06:58] over 300 licenses,
[2:07:00] and we have over 300 licenses
[2:07:02] that are ongoing.
[2:07:04] Well, I'm going to have
[2:07:04] to yield back,
[2:07:05] but I assist that's
[2:07:06] a little short of the target.
[2:07:07] I yield back, Mr. Chairman.
[2:07:08] The gentleman yields.
[2:07:09] The chair now recognizes
[2:07:10] the gentleman from Ohio,
[2:07:12] Mr. Lansman,
[2:07:13] for his five minutes
[2:07:14] of questioning.
[2:07:16] Thank you, Mr. Chair.
[2:07:17] Thank you all for being here.
[2:07:19] A couple questions.
[2:07:20] One is,
[2:07:23] it seems based on the testimony
[2:07:24] that you all have provided,
[2:07:27] one of the biggest ways
[2:07:30] in which you are getting fraud,
[2:07:33] tackling fraud,
[2:07:35] is the investments
[2:07:36] that you're making, right?
[2:07:38] So whether it's
[2:07:38] technological investments,
[2:07:40] staffing,
[2:07:41] I mean, the more,
[2:07:42] you know, cops on the beat,
[2:07:43] so to speak,
[2:07:44] the more fraud you're going to get.
[2:07:46] And I'm hoping that each one of you
[2:07:48] could just list out
[2:07:50] the investments
[2:07:51] that you all have made
[2:07:53] in going after fraud.
[2:07:55] I'll start with Minnesota.
[2:07:59] Thank you, Representative Lansman.
[2:08:01] So I'll start with Governor Walz's
[2:08:03] Executive Order 2510
[2:08:05] in September of 2025,
[2:08:06] directing the state
[2:08:08] to take a number of actions
[2:08:09] to strengthen its anti-fraud efforts.
[2:08:12] And of course,
[2:08:12] the Department of Human Services
[2:08:13] as the Medicaid agency
[2:08:14] was front and center in that.
[2:08:16] And as I described earlier,
[2:08:18] and I appreciate the opportunity
[2:08:19] to say more,
[2:08:20] many different policy changes
[2:08:22] were made as a result of that.
[2:08:24] We implemented,
[2:08:25] of course,
[2:08:26] the high-risk designations,
[2:08:27] which heightens provider compliance.
[2:08:30] Just list the top three
[2:08:34] or four investments.
[2:08:35] What new things are in place?
[2:08:38] You bet.
[2:08:38] So I'll start with
[2:08:39] enhanced prepayment review.
[2:08:40] That is a new process
[2:08:42] that's entirely new.
[2:08:43] We have, you know,
[2:08:45] external vendors helping us with that
[2:08:46] and staff working on that.
[2:08:48] We had 450 new staff
[2:08:49] given to us
[2:08:51] as a result of the legislation
[2:08:53] passed this year
[2:08:54] to enhance program integrity
[2:08:56] in addition to new data analytics capacities.
[2:08:59] I'll stop there.
[2:09:00] That's significant.
[2:09:01] I mean, that's a lot of new staff.
[2:09:04] California, sorry.
[2:09:07] Thank you, Congressman.
[2:09:08] So just as a baseline,
[2:09:10] approximately 20% of our staff
[2:09:12] are dedicated exclusively
[2:09:13] to program integrity.
[2:09:15] We've made several new investments
[2:09:16] to strengthen the integrity of the program
[2:09:19] based on lessons learned.
[2:09:21] One example is strengthening
[2:09:22] our eligibility determination processes
[2:09:25] based on our experience
[2:09:27] with the stolen identities
[2:09:29] of individuals being used to enroll.
[2:09:31] So we have multiple new residency safeguard checks
[2:09:34] as well as new technology
[2:09:35] to detect bad actors
[2:09:38] trying to mask their identity.
[2:09:40] So remote spoofing detection,
[2:09:42] virtual private networks, et cetera.
[2:09:44] Another example is a new investment
[2:09:46] in sophisticated data analytics
[2:09:49] in our pharmacy benefit in particular,
[2:09:51] partnering with our vendor
[2:09:54] using Google Cloud Platform
[2:09:57] and machine learning
[2:09:58] to not just have static rules-based prepayment,
[2:10:01] but this is training based on our data
[2:10:03] to actively learn, adapt, and evolve
[2:10:05] in real time based on the patterns in the data.
[2:10:08] Samar, New York.
[2:10:10] Thank you for the question.
[2:10:12] Similar to what you've heard,
[2:10:13] we've made investments in people
[2:10:15] and program integrity staff over the years
[2:10:17] at the Office of Medicaid Inspector General.
[2:10:20] We've also staffed up, as I mentioned before,
[2:10:23] on implementation of H.R.1,
[2:10:25] and a lot of that includes program integrity-related
[2:10:28] or managed care oversight-related staff,
[2:10:30] technology on eligibility and enrollment system,
[2:10:34] new provider enrollment system,
[2:10:36] and data analytics to do more risk-based stratification,
[2:10:41] identify providers before the fraud occurs
[2:10:44] and try and proactively address that.
[2:10:48] Ohio.
[2:10:49] Congressman, thank you.
[2:10:51] To your point,
[2:10:51] the investments in those data infrastructure
[2:10:53] have been incredibly helpful,
[2:10:55] not just for fighting fraud,
[2:10:56] but for also identifying areas of waste and abuse.
[2:10:58] The move to a single pharmacy benefit manager in Ohio,
[2:11:01] as well as building out a single fiscal intermediary,
[2:11:03] has been incredibly helpful,
[2:11:05] not just from observing fraudulent trends,
[2:11:07] but when making policy decisions
[2:11:08] to be able to dive deep into the data.
[2:11:11] We've frequently been told by policymakers and legislators
[2:11:13] just how incredibly helpful that has been
[2:11:15] as we have navigated difficult decisions
[2:11:17] to tackle waste
[2:11:18] and where dollars maybe are spent not as intended.
[2:11:21] To be able to really drill down
[2:11:22] and see where those are going
[2:11:24] has been incredibly helpful
[2:11:26] to all of our conversations.
[2:11:28] And this is just maybe a yes or no
[2:11:30] because I only got 40 seconds left.
[2:11:32] Do you think Congress is providing
[2:11:34] enough support, investments?
[2:11:37] Let me ask this in a less leading way.
[2:11:39] Same leading,
[2:11:40] but maybe it's a little easier to answer.
[2:11:42] Could Congress be investing more in states
[2:11:46] and their ability to go after fraud?
[2:11:49] Yes or no?
[2:11:51] Yes, absolutely.
[2:11:52] Yes, there are a few key areas
[2:11:54] where Congress could enhance states
[2:11:56] and better equip them in this space.
[2:11:59] Yes.
[2:12:01] Yeah.
[2:12:02] Yes, we would never turn down additional help.
[2:12:03] Yeah.
[2:12:04] If you see, 10 seconds,
[2:12:06] it seems like the states
[2:12:07] that are really good at this
[2:12:08] have invested a lot of resources into it,
[2:12:12] and that's what we should be doing.
[2:12:14] Among other things, it's helping states
[2:12:16] invest in those efforts to go after fraud.
[2:12:19] Thank you, I yield back.
[2:12:20] Gentleman yields.
[2:12:21] The chair now recognizes
[2:12:22] the gentleman from Florida,
[2:12:24] Mr. Bill Arrakis,
[2:12:25] for his five minutes of questioning.
[2:12:26] Thank you, Mr. Chairman.
[2:12:27] And I want to thank you
[2:12:29] for holding this hearing,
[2:12:31] very important hearing,
[2:12:32] protecting patients
[2:12:33] and safeguarding taxpayer dollars.
[2:12:36] Thank you for allowing me
[2:12:38] to wave on, too,
[2:12:38] and I appreciate the testimony.
[2:12:41] Every dollar lost
[2:12:42] to improper payments
[2:12:44] is a dollar
[2:12:44] that cannot be used
[2:12:46] to support seniors,
[2:12:48] children,
[2:12:48] individuals with disabilities
[2:12:50] and other vulnerable populations
[2:12:52] who rely on these
[2:12:53] very critical programs.
[2:12:55] That's why I'm pleased
[2:12:57] to introduce
[2:12:57] the Medicaid RAC Improvement Act
[2:13:00] this week,
[2:13:01] alongside with Senator Scott,
[2:13:04] who is introducing
[2:13:05] the companion in the Senate.
[2:13:07] Recovery adult contractors
[2:13:10] have served
[2:13:11] as an important payment
[2:13:12] integrity tool for Medicaid,
[2:13:15] but Medicaid itself
[2:13:16] has changed significantly
[2:13:18] since these programs
[2:13:19] were first established.
[2:13:21] Today, much of Medicaid spending
[2:13:23] flows through managed care,
[2:13:25] while oversight has struggled
[2:13:26] to keep pace.
[2:13:28] My legislation implements
[2:13:30] recommendations made
[2:13:31] by the Government Accountability Office
[2:13:33] by strengthening CMS oversight
[2:13:36] of Medicaid
[2:13:37] RAC programs,
[2:13:39] improving transparency
[2:13:40] and accountability
[2:13:42] and helping ensure
[2:13:43] the payment integrity efforts
[2:13:45] appropriately reflect
[2:13:48] the modern Medicaid program.
[2:13:50] I appreciate the committee's
[2:13:51] continued focus
[2:13:52] on program integrity
[2:13:54] and thank the witnesses again
[2:13:56] for being here today.
[2:13:58] We really appreciate y'all.
[2:13:59] You're adding so much
[2:14:00] to the discussion.
[2:14:02] My first question is
[2:14:05] for Director Sadowith
[2:14:07] and Director Basiri
[2:14:09] and Temporary Commissioner Conley.
[2:14:12] Does your state
[2:14:14] have Medicaid recovery
[2:14:16] audit contractor programs?
[2:14:19] Does it have a program
[2:14:20] that currently reviews payments
[2:14:23] made through Medicaid
[2:14:25] managed care organizations
[2:14:26] or is it just fee-for-service?
[2:14:29] We'll start with
[2:14:31] Director Sadowith.
[2:14:34] Thank you, Representative.
[2:14:35] My understanding is
[2:14:37] that our RAC program
[2:14:38] is limited to fee-for-service.
[2:14:40] We have a number
[2:14:41] of additional tools in place
[2:14:42] to perform
[2:14:43] sort of integrated analytics
[2:14:45] to identify risk trends
[2:14:47] and patterns
[2:14:47] in our managed care delivery system
[2:14:49] as well.
[2:14:50] Thank you.
[2:14:51] Now, Director Basiri, please.
[2:14:55] My understanding is
[2:14:56] that our RAC program
[2:14:57] is also specific
[2:14:58] to fee-for-service,
[2:14:59] but we have other oversight,
[2:15:01] overpayment,
[2:15:02] and improper payment mechanisms
[2:15:04] for managed care,
[2:15:05] particularly third-party liability.
[2:15:07] Thank you.
[2:15:07] And then Commissioner Conley.
[2:15:10] Thank you, Representative Borakis
[2:15:12] for the question.
[2:15:13] My understanding,
[2:15:14] I would have to confirm
[2:15:15] on the managed care side,
[2:15:16] my understanding is
[2:15:17] we absolutely,
[2:15:18] I can confirm,
[2:15:19] have a recovery,
[2:15:21] a RAC contractor
[2:15:22] for the fee-for-service program,
[2:15:24] and we also implemented
[2:15:25] new managed care contract requirements
[2:15:26] with respect to staffing
[2:15:28] that they have
[2:15:29] for program integrity
[2:15:30] recovery timelines
[2:15:31] in addition to payment
[2:15:33] withhold timelines as well
[2:15:34] that are required
[2:15:35] in that contract.
[2:15:36] Okay, the follow-up question.
[2:15:38] How often do you audit
[2:15:40] or validate
[2:15:40] whether encounter data
[2:15:42] submitted by managed care
[2:15:44] organizations accurately
[2:15:45] reflects actual payment
[2:15:47] made to providers?
[2:15:49] And we'll start again
[2:15:49] with Director Sadweth, please.
[2:15:53] Thank you, Representative.
[2:15:54] So we have a number
[2:15:56] of processes in place
[2:15:57] to validate managed care
[2:15:59] and counter data,
[2:16:00] both internal processes
[2:16:02] as well as processes
[2:16:04] in place
[2:16:04] with external entities.
[2:16:06] Thank you.
[2:16:07] Director Burseri.
[2:16:08] We have several mechanisms
[2:16:09] in place,
[2:16:10] including state laws
[2:16:11] and penalty programs
[2:16:12] to ensure completeness
[2:16:14] and accuracy
[2:16:14] of our managed care
[2:16:16] and counter data,
[2:16:16] and we use that encounter data
[2:16:18] for as much
[2:16:19] in rate setting
[2:16:20] as the actuary will allow.
[2:16:22] Very good.
[2:16:22] And Commissioner Conley.
[2:16:25] Similarly,
[2:16:26] we have very complete
[2:16:27] claims data
[2:16:28] from managed care plans
[2:16:29] that we use
[2:16:30] to analyze trends
[2:16:32] and different issues
[2:16:33] with those claims.
[2:16:34] Very good.
[2:16:35] Another question,
[2:16:36] follow-up question.
[2:16:38] If managed care payments
[2:16:39] are excluded
[2:16:40] from RAC audits,
[2:16:43] how are you independently
[2:16:44] validating the accuracy
[2:16:46] of those payments?
[2:16:47] And again,
[2:16:47] you touched on it,
[2:16:49] but let's elaborate
[2:16:50] if possible.
[2:16:52] If you don't mind,
[2:16:53] we'll start
[2:16:53] with Director Sadweth.
[2:16:55] Thank you, Congressman.
[2:16:57] So we do have a number
[2:16:58] of processes in place
[2:16:59] to validate the accuracy
[2:17:02] and completeness
[2:17:03] of encounter data.
[2:17:04] We have been working
[2:17:06] with plans
[2:17:07] to sort of increase
[2:17:09] the rate
[2:17:11] to which encounter data
[2:17:12] are incorporated
[2:17:12] in managed care
[2:17:13] rate setting processes,
[2:17:15] and we have
[2:17:15] a stoplight program
[2:17:16] that provides feedback
[2:17:18] and corrective action plans
[2:17:19] to improve their
[2:17:21] managed care
[2:17:22] and counter data submissions.
[2:17:24] This is an ongoing process
[2:17:25] that's absolutely key
[2:17:26] to quality measurement
[2:17:27] to data accuracy
[2:17:28] and to rate setting.
[2:17:30] Very good.
[2:17:31] Director Berseri.
[2:17:34] In addition to what
[2:17:35] I mentioned before
[2:17:36] with the statute
[2:17:37] and penalty programs
[2:17:38] to ensure compliance,
[2:17:40] we have a very,
[2:17:41] our Medicaid model contract
[2:17:43] has a number of provisions
[2:17:44] around third-party liability,
[2:17:46] and our Office of Medicaid
[2:17:48] Inspector General
[2:17:49] works very closely
[2:17:50] with the plans
[2:17:50] to ensure
[2:17:51] appropriate coordination
[2:17:53] of benefits.
[2:17:54] Thank you.
[2:17:55] Commissioner Conley.
[2:17:56] Thank you.
[2:17:57] Similarly, we have requirements
[2:17:58] with respect to claims
[2:18:00] and data collection
[2:18:01] from the plans.
[2:18:02] Our Inspector General
[2:18:03] also works very closely
[2:18:04] with the plans
[2:18:05] and their program
[2:18:06] integrity staff
[2:18:07] to follow up
[2:18:07] on credible allegations
[2:18:08] of fraud.
[2:18:10] Thank you very much.
[2:18:10] I have a question
[2:18:11] for Director for Tick Card,
[2:18:13] but I'll submit it
[2:18:14] for the record.
[2:18:15] I appreciate it.
[2:18:16] I'll yield back,
[2:18:16] Mr. Chairman.
[2:18:17] Thanks for giving me
[2:18:18] the extra time.
[2:18:19] The gentleman yields.
[2:18:20] Seeing there are no further members
[2:18:22] wishing to ask questions,
[2:18:23] I would like to thank
[2:18:24] our witnesses again
[2:18:25] for being here.
[2:18:26] I ask unanimous consent
[2:18:28] to insert into the record
[2:18:29] the documents included
[2:18:30] on the staff hearing
[2:18:31] documents list.
[2:18:33] Without objection,
[2:18:34] so ordered.
[2:18:35] Pursuant to committee rules,
[2:18:37] I remind members
[2:18:38] that they have 10 business days
[2:18:39] to submit additional questions
[2:18:41] for the record,
[2:18:42] and I ask our witnesses
[2:18:43] to submit their response
[2:18:44] within 10 business days
[2:18:46] upon receipt
[2:18:47] of those questions.
[2:18:49] Members should submit
[2:18:49] their questions
[2:18:50] by the close of business day,
[2:18:51] Friday, July 10th.
[2:18:53] Without objection,
[2:18:55] the subcommittee is adjourned.
[2:18:56] All rights reserved.
[2:18:58] There are not
[2:18:58] any questions
[2:18:58] that you can get
[2:18:59] over to.
[2:19:00] There are not
[2:19:01] that you will get
[2:19:01] and that you will get
[2:19:01] the news.
[2:19:02] Are you listening to this before?
[2:19:03] The next slide is
[2:19:04] on Twitter.
[2:19:05] The next slide is
[2:19:05] on Twitter.
[2:19:05] When you are listening
[2:19:06] to the Instagram
[2:19:07] at the pada412,
[2:19:07] the next slide is
[2:19:08] on Twitter.
[2:19:08] It is on Twitter.
[2:19:09] It is on Twitter.
[2:19:10] It is on Twitter.
[2:19:11] It is on Twitter.
[2:19:11] It is on Twitter.
Related Transcripts from FOX 9 Minneapolis-St. Paul