Wednesday, June 9, 2010

Child Medicaid Fraud Control Model

The Department of Justice requires all agencies to post contractor performance evaluations entities in Past Performance Information Retrieval System (PPIRS).

In July 2002, DoD endorsed the Past Performance Information Retrieval System as the single, authorized application to retrieve contractor performance information. PPIRS is a web-enabled, enterprise application that provides timely and pertinent contractor past performance information to the Department of Defense and Federal acquisition community for use in making source selection decisions. PPIRS assists acquisition officials by serving as the single source for contractor past performance data. Confidence in a prospective contractor's ability to satisfactorily perform contract requirements is an important factor in making best value decisions in the acquisition of goods and services.  PPIRS consists of two components, Report Card (RC) and Statistical Reporting (SR).  Both components support the Federal Acquisition Regulation (FAR) requirement to consider past performance information prior to making a contract award (FAR Parts 15, 36 and 42).
Government access is restricted to those individuals who are working on source selections, to include contractor responsibility determinations. Contractors may view only their own data. A contractor must be registered in the Central Contractor Registration (CCR) system and must have created a Marketing Partner Identification Number (MPIN) in the CCR profile to access their PPIRS information.
PPIRS fulfills the needs of procurement and acquisition regulation deficiencies for the child welfare industry.

For the purposes of tackling the issues of perversely aberrant billing in child welfare, accountability and transparency in child welfare services will be examined as a policy procurement process that encourages the efficient, effective and ethical use of state resources in the best interest of stakeholders for the cycle of development of policy. A government agency and its officials have the responsibility of ensuring that any process for the development of policy is open and transparent, and that decisions are justified. Government agencies, private agencies, and elected officials need to have procedures in place to ensure that the policy processes are conducted soundly and that development related actions are documented, defensible and substantiated in accordance with state and federal legislation and policy.

Accountability and transparency are primary considerations throughout the cyclical process of policy, from the initial identification of need to the final decision of policy. A well planned, conducted and documented process of policy development, which accords with government policy, is more likely to withstand external scrutiny. If a policy is subject to scrutiny and adherence to the traditional standards of government, full documentation of the process can be relied upon to provide substantiation of decisions. Accountability means that officials are responsible for the actions and decisions that they take in relation to policy procurement and for the resulting outcomes. Officials are answerable for such activities through established lines of accountability in the organizational structure of agencies and government.

Transparency provides assurance that the policy procurement processes undertaken by agencies and the legislature are appropriate that policy and legislative obligations are being met. Transparency involves agencies taking steps to support appropriate scrutiny of their procurement activity.  This activity is not limited to the government, but, in situations of privatization, encompasses the activities of contracted private agencies, meaning child welfare organizations.  The stakeholders have been identified and placed in the appropriate positions of the contracted organization to examine the performance and ethics and financial integrity of the operations.

State officials undertaking policy development are accountable for complying with relevant these acquisition and procurement policies and legislative requirements. This includes the specific policies and legislative requirements set out in the constitution and the provisions of policies and legislation that interact with policy development.

Documentation is critical to accountability and transparency. It provides a record of procurement activities and how they have been conducted.  It facilitates scrutiny of these activities. Agencies must maintain appropriate documentation for each policy procurement. The appropriate mix and level of documentation depends on the nature and risk profile of the policy procurement being undertaken. In all cases, officials need to ensure there is sufficient documentation to provide an understanding of the reasons for the procurement, the process that was followed and all relevant decisions, including approvals and authorizations, and the basis of those decisions.

Documentation relating to a procurement of policy is not limited to reactionary measures taken by the government and agencies to address the issues of the state. Documentation must entail and require a set of recorded data collection for inputs and outputs of the system. In addition, the government sets out requirements in relation to public records, including dealings with, and access to, such records. This is known as the exceptions and exclusions of the Freedom of Information.

Some specific requirements for the preparation of documentation that supports the spending of public monies are set out in the state and federal regulations. Documentation requirements vary throughout the policy procurement cycle. Documentation that may be appropriate for each stage includes, but is not limited to, annual plan for policy development, risk assessment, legal advice, policy method decision, evaluation plan, including selection criteria, policy development budget, time limits and timetable, plan of a probability for implementation, evaluation plan, due diligence process, evaluation report and recommended decision. Continuing the list of documentation requirements will include the oversight of management of contract relations: contract management plan, performance indicators, milestones, performance reports, correspondence between the parties, requests for variation of the contract, decisions regarding variation, records of the receipt of orders, evaluations of property and/or services, payment information.

It is an agency's responsibility to ensure that adequate and appropriate documentation is kept for each stage of policy development. Where agencies have outsourced the provision of services, they are to ensure that the providers maintain appropriate systems for recording decisions relating to the outsourced services, and the reasons for those decisions.

Disclosure:Disclosure is the mechanism by which agencies make their procurement activities visible and transparent. The broad aim of disclosure is to provide confidence in the processes that an agency intends to undertake, or has undertaken, and reassurance that the Chief Executive is promoting the efficient, effective and ethical use of resources.

Reporting: Agencies are required to comply with a range of specific reporting obligations, detailed below, to provide broader visibility of their procurement, including to the State government, its Committees, and to the public.  Annual reporting requirements are an important accountability mechanism, informing the government and other stakeholders of agencies' performance in relation to the services that they provide. A framework for the major aspects of child welfare agencies' annual reports and various other reporting and disclosure obligations should be applicable, including where confidential information is required to be disclosed following a request from a legislative committee.

Dealing with Complaints: Policy procurement processes need to be based on clearly articulated and defensible evaluation criteria consistent with the procurement policy framework. Agencies' actions in undertaking policy development must be robust and defensible. The complaint handling function is essentially confined to the provision of information relating to policy procurement policy, and so the person making the complaint is referred to the agency, which conducted the relevant policy procurement process; discovered and identified in this analysis as the Office of Attorney General.

In the event that a complaint is received private agencies and governmental departments should aim to manage this process internally, where possible, through communication and conciliation with the grievant. Agencies need to have fair, equitable and non-discriminatory complaint handling procedures that take account of the following: the process needs to be systematic and be well understood by the parties involved; senior management and officials independent of the process should be involved as appropriate; complaints should be dealt with in writing; each party must have sufficient time to appropriately respond to developments; if a matter has been referred to an external body for review, agencies may be required to provide all relevant documents to that body as required by law; and agencies must ensure that the initiation of a complaint process does not prejudice a parent or guardian's participation in future legal processes.

External options are available if independent review of a complaint is necessary. The primary external complaint mechanism is the civil legal system, which can be used to settle matters through a judicial process. In consideration of the limitations the public has in access legal representation, mostly financial, there is even more need for the States Medicaid Fraud Control Units to adopt this PPIRS model to end Medicaid fraud, adopt policies for contractual debarment, license revocation, fines, sanctions and the ability to aggressively prosecute and recover fraudulent and improperly reimbursed funds from these contracted entities.

Department of Justice Procurement Advisory 2010

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