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Medicaid program integrity

Program integrity is an integrated system of activities designed to ensure compliance with federal, state, and agency statutes, rules, regulations, and policies. It includes reasonable and consistent oversight of the Washington Apple Health program (Medicaid).

Review the program integrity metrics for additional information.

Annual program integrity metrics

Through teamwork within HCA and with its partners, program integrity:

  • Supports awareness and responsibility for administering public funds.
  • Encourages compliance where providers and managed care entities are able to self-disclose improper payments.
  • Holds managed care entities accountable to have systems in place to prevent improper billing and payments.
  • Recognizes areas of vulnerabilities that adversely affect Apple Health programs.
  • Ensures providers meet program participation requirements.
  • Ensures clients meet program eligibility requirements.
  • Ensures Apple Health is the payor of last resort, except for an eligible client covered under Indian Health Service (IHS), IHS is the payor of last resort.
  • Investigates all leads and referrals to determine evidence of potential fraud, waste or abuse.
  • Conducts activities to detect and prevent fraud, waste and abuse, and identify any associated improper payments. Activities include but are not limited to:
    • Running data analytics and algorithms
    • Creating provider utilization profiles
    • Conducting audits and clinical reviews
    • Investigating potential credible allegations of fraud
    • Applying payment suspensions
    • Performing provider terminations
    • Reporting individual and entity exclusions
    • Invoking managed care entity sanctions
    • Conducting provider outreach and education
    • Implementing payment system edits
    • Maintaining program policies and rules
    • Complying with federal initiatives

State Fiscal Year (SFY) 2018

Through algorithms, audits, and clinical reviews*, the efforts of the Health Care Authority's (HCA) Section of Program Integrity (PI) resulted in the following identified improper payments, recoveries, cost-avoidance, and savings.

Improper payments identified Improper payment recoveries Cost avoidance Total recoveries and savings
$50,377,171 $51,651,148 $28,216,217 $79,867,366

*This does not include activities resulting in recoveries, cost avoidance, and cost savings performed outside of HCA’s Section of Program Integrity.

*During SFY 2018, no audits were conducted by an audit contractor, i.e., Medicaid Recovery Audit Contractor (RAC), Medicaid Integrity Contractor (MIC) or Unified Program Integrity Contractor (UPIC).