Executive Order RP36 - July 12, 2004

Transcription

1 Department f Internal Auditing Page 1 f 5 SECTION A-16 Executive Order RP36 - July 12, 2004 Relating t preventing, detecting, and eliminating fraud, waste and abuse. BY THE GOVERNOR OF THE STATE OF TEXAS Executive Department Austin, Texas July 12, 2004 WHEREAS, gvernment has a sacred trust t guard taxpayers' dllars and maintain the highest standard f integrity, impartiality and cnduct, and cntractrs fr state services have a fiduciary respnsibility t prevent, detect and reprt fraud; and WHEREAS, the State f Texas is entrusted by the taxpayers f the state t prvide respnsible stewardship thrugh efficient and hnest gvernance, and all state agencies have a respnsibility t prevent and eliminate fraud, and every state emplyee has an affirmative respnsibility t reprt incidents f fraud; and WHEREAS, the Gvernr asked the State Agency Crdinating Cuncil, the Mid-Size Agency Crdinating Cuncil, and the Small State Agency Task Frce, t cnvene a fraud preventin and detectin wrkgrup; and WHEREAS, the United States Department f Labr estimates that during calendar year 2001, abut $2.4 billin in verpayments ccurred in the unemplyment insurance system natinwide, with abut $577 millin (24 percent) attributable t fraud r abuse; and WHEREAS, the immediate reductin in benefit fraud and claims verpayments wuld substantially impact the slvency f the Unemplyment Insurance Trust Fund and wuld benefit emplyers and citizens by further prmting the gals f the unemplyment insurance system; and WHEREAS, effective and innvative state plicies, system management, and peratinal practices can address and limit unemplyment benefit fraud and claims verpayments, and the Texas Wrkfrce Cmmissin is uniquely qualified with the general pwers and duties under Labr Cde, Sectin , and Subchapter E t address these issues; and WHEREAS, fraud and abuse in the health care system affects all Texans by increasing health care csts, nt nly t state prgrams but als t all participants in the private health industry; and WHEREAS, fraud and abuse by administrative cntractrs, health care prfessinals, r clients in the Medicaid prgram undermines bth the purpse f the prgram and the trust f the taxpayers wh fund the prgram; and

2 Department f Internal Auditing Page 2 f 5 WHEREAS, fraud r abuse reduces funds available t prvide health care and ther vital services t Texans; and WHEREAS, pprtunities exist t identify best practices fr treatment and billing prcedures that ensure apprpriate and cst-effective participatin in the Medicaid prgram by health care prfessinals and facilities; and WHEREAS, pprtunities still exist t fight fraud and abuse by requiring crdinatin between the health prfessins licensure bards, insurance carriers, emplyers, patients, and gvernment prgrams; and WHEREAS, cmmunicatins between health prfessins licensure bards and the Office f the Attrney General, Health and Human Services Cmmissin, Texas Wrkers' Cmpensatin Cmmissin, and Department f Insurance must be established t allw mre effective detectin, investigatin, and prsecutin f fraud and abuse cmmitted by health prfessinals participating in state and federal health prgrams; and WHEREAS, the Texas Department f Insurance is a natinal leader in detecting and preventing fraud and abuse, and additinal pprtunities exist fr imprving detectin, investigatin and prsecutin f fraud and abuse in the private insurance market; and WHEREAS, wrkers' cmpensatin fraud hinders ecnmic develpment and jb creatin, (in fiscal year 2003 the Texas Wrkers' Cmpensatin Cmmissin referred t prsecutrs mre than $10 millin in fraud cases) and additinal pprtunities exist fr imprving detectin, investigatin and prsecutin f allegatins f fraud and abuse in the wrkers' cmpensatin system; NOW, THEREFORE, I, Rick Perry, Gvernr f Texas, by virtue f the pwer and authrity vested in me by the Cnstitutin and laws f the State f Texas d hereby rder the fllwing: 1. Detect and Fight Fraud in Gvernment. Each state agency shall cmply with the fllwing initiatives and directives t prevent, detect, and eliminate fraud, waste, and abuse in state gvernment. The state agency wrkgrup shall submit a reprt t the Office f the Gvernr. The reprt shall include: a. risk assessment tls t help agencies determine vulnerabilities; b. best practices that eliminate fraud in cntracting, cntract management and prcurement; and c. cmmn cmpnents fr fraud preventin and eliminatin prgrams. Each agency must designate a cntact persn fr its fraud preventin and eliminatin activities; the cntact persn shall reprt directly t the agency executive directr, cmmissiner, r bard chair. Each agency shall develp a fraud preventin prgram that includes, at a minimum, the recmmended cmmn cmpnents develped by the state agency wrkgrup.

3 Department f Internal Auditing Page 3 f 5 These prgrams must be in place by Octber 1, If an agency already has a fraud preventin and eliminatin prgram, the agency shall ensure that its prgram includes the recmmended cmmn cmpnents. Each agency shall review its existing rules, plicies, rganizatinal structure and statutes t identify changes needed t better detect and fight fraud. Each agency shall reprt its actins t cmply with this executive rder and any recmmended statutry changes t imprve its fraud preventin and eliminatin effrts t the anti-fraud crdinatr in the Office f the Gvernr n later than Octber 1, Target Fraud in the Unemplyment Insurance Prgram. The Texas Wrkfrce Cmmissin shall priritize preventin, detectin and eliminatin f fraud and abuse in the Unemplyment Insurance Prgram. The Texas Wrkfrce Cmmissin shall identify any state plicies, management and peratinal practices, weaknesses in existing cmputer crss-matching systems, and ther apprpriate factrs that are ineffective in preventing and detecting fraud and abuse in the Unemplyment Insurance Prgram. The Texas Wrkfrce Cmmissin shall develp innvative strategies t address benefit fraud and claims verpayments, identify any wrker misclassificatin resulting in underpayments t the Unemplyment Insurance Trust Fund, and imprve claimants' jb search and placement strategies in rder t reduce the percentage f claimants wh exhaust unemplyment cmpensatin benefits. The Texas Wrkfrce Cmmissin shall identify and implement natinal best practices fr detecting and prsecuting fraudulent schemes, identify cst-effective strategies designed t eliminate fraud, reduce benefit payment inaccuracies, and increase recvery f claims verpayments and emplyer delinquent accunts. The Texas Wrkfrce Cmmissin shall make recmmendatins n the benefit f authrizing the cmmissin t enter int cntractual arrangements with private cllectin agencies t assist in pursuing uncllected verpayments f unemplyment benefits. The Texas Wrkfrce Cmmissin shall implement a cmprehensive prcess t prmte high quality benefit determinatin and avid imprper disqualificatin r denial f benefits. The Texas Wrkfrce Cmmissin shall increase the prfile f its fight against fraud n its website.

4 Department f Internal Auditing Page 4 f 5 3. Target Fraud in the Health Care System. All state agencies that perate prgrams r regulate participants f the health care system shall fcus n the preventin, detectin, and eliminatin f fraud and abuse in the health care system. The Health and Human Services Cmmissin and Office f the Attrney General shall use all available resurces t pursue Medicaid fraud cases against individuals and entities. Punishment f these vilatrs may include administrative, civil, and criminal penalties. When vilatins indicate bth civil and criminal intent, bth civil and criminal penalties shall be pursued. The Health and Human Services Cmmissin, thrugh its agreement with the Centers fr Medicare & Medicaid Services, shall cnduct a cmputer matching prgram t study claims, billing, and eligibility infrmatin t detect Medicare and Medicaid fraud and abuse in Texas. The Office f Inspectr General and Health and Human Services Cmmissin shall braden technlgy use and develp and implement aggressive deplyment f technlgical tls which can: a) reveal patterns f behavir by prviders and allw investigative resurces t target any inapprpriate practice patterns; and b) thrugh imprved educatin f prviders and recipients, fcus n reducing expenditures fr services that are nt medically necessary r justified. All health prfessins licensure bards shall crdinate and cperate with ther relevant state agencies t create seamless disciplinary systems fr health care prfessinals that eliminate incnsistencies between disciplinary actins taken by the different state entities respnsible fr versight f health care prfessinals. The Health Prfessins Cuncil shall cnvene a wrk grup cnsisting f a ttal f fur members frm licensure bards, and ne representative each frm the Office f Attrney General, Health and Human Services Cmmissin, Texas Wrkers' Cmpensatin Cmmissin, and Department f Insurance t develp a cnsistent set f plicies fr the health prfessins licensure bards t adpt t ensure cnsistent applicatin f plicies and practices fr detecting, investigating, and prsecuting fraud and abuse as well as fr sharing infrmatin with ther state agencies regarding allegatins f fraud and abuse by health care prfessinals in gvernment prgrams. The Department f Insurance shall peridically disseminate best practices infrmatin t assist insurers, law enfrcement persnnel, prsecutrs and ther persns invlved in insurance transactins t enhance fraud detectin, reprting, investigatin, and

5 Department f Internal Auditing Page 5 f 5 prsecutin f all types f insurance fraud, as well as t encurage imprvement and implementatin f anti-fraud plans submitted by carriers. The Department f Insurance shall increase the public prfile f its effrts t address fraud and abuse, including the recent Fraud Cnference; the availability f training t identify fraud and abuse; the tll-free htline, t reprt fraud; the webpage dedicated t the reprting f fraud; the availability f prsecutr and investigatin assistance by the department; and crdinatin with ther state and lcal agencies. The agency shall further increase partnerships t identify, investigate and prsecute fraud and abuse in all types f insurance by prviders, insurers, agents, and claimants. The Texas Wrkers' Cmpensatin Cmmissin shall use enhanced technlgy and develp and implement aggressive deplyment f technlgical tls t reveal patterns f behavir by system participants and target investigative resurces twards inapprpriate patterns. The Texas Wrkers' Cmpensatin Cmmissin shall increase the public prfile f its effrts t address fraud and abuse, t dedicate a web-page t fraud reprting, and t crdinate effrts with ther state agencies. The Cmmissin shall further prmte reprting f fraud n the tll-free Fraud Htline, , and n-line at The cmmissin als shall increase partnerships t identify, investigate and prsecute fraud and abuse in the wrkers' cmpensatin system. This executive rder shall supersede all previus executive rders n the same issue and shall remain in effect until mdified, amended, rescinded, r superseded by me r by a succeeding Gvernr. Given under my hand this the 12th day f July, RICK PERRY Gvernr ATTESTED BY: GEOFFREY S. CONNOR Secretary f State