Programs & initiatives

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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 (WAH) program (Medicaid).

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 WAH programs
  • Ensures providers meet program participation requirements
  • Ensures clients meet program eligibility requirements
  • Ensures WAH 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 2016

Program Integrity Algorithm, Audit and Clinical Review*

Identified Improper Payments, Recoveries and Savings

Improper Payments Identified Improper Payment Recoveries Cost Avoidance Cost Savings Total Recoveries and Savings
$23,304,352 $20,930,222 $16,131,798 $493,096 $37,555,116

*Other activities outside of HCA's Section of Program Integrity resulting in recoveries, cost avoidance and cost savings are not captured in this table.