Wisconsin Family Planning and Reproductive Health Association.

January 29, 2015
Representative Samantha Kerkman, Co-Chair
Joint Legislative Audit Committee
315 North, State Capitol
Madison, WI 53702
Senator Robert Cowles, Co-Chair
Joint Legislative Audit Committee
118 South, State Capitol
Madison, WI 53702
RE: Legislative Request for Audit of Medicaid Family Planning Reimbursement
Dear Representative Kerkman and Senator Cowles:
The Wisconsin Family Planning and Reproductive Health Association is a statewide professional
association of providers, organizations, and advocates committed to high quality, low cost and confidential
reproductive health care services to people of all ages and incomes throughout Wisconsin. Our members
include Wisconsin Medicaid certified providers. WFPRHA conducts trainings and provides resources to
our members to promote best practices and compliance with Medicaid statutes, regulations, and billing
We have learned that you received a request from multiple legislators to conduct a “comprehensive,
independent audit of Wisconsin’s Medicaid family planning providers.” The request follows media
accounts of recent audits conducted by the Department of Health Services Office of the Inspector General. 1
We would welcome a comprehensive, independent review of the audit process being applied by the DHS
Office of the Inspector General. We believe that if the Legislative Audit Bureau examined the Medicaid
statutes, regulations, and published reimbursement rates, and compared those to the standards being applied
by the Office of the Inspector General, it would find a significant and troubling disconnect.
The serious concern raised in the media reports is not that the clinics have been overpaid; they have not. It
is not that clinics have been ignoring regulations; they have not. Rather, the concern is the Inspector
General’s retroactive application of a non-existent reimbursement rate to claim that the providers have been
overpaid for years, along with a demand for repayment.
available at: http://wisconsinwatch.org/2014/11/family-planning-clinics-say-state-audits-could-forcemany-to-close/ and http://www.jsonline.com/business/state-to-family-planning-clinics-you-owe-usmillions-b99407628z1-285669921.html
Wisconsin Family Planning and Reproductive Health Association
719 North Third Ave., Wausau, WI 54401
(715)675-9858 – fax (715)675-5475 – [email protected]
To put it simply:
Since 2003, Wisconsin Medicaid has told family planning clinics what Medicaid will reimburse for
medication (through Maximum Fee Schedules, Provider Updates, and Terms of Reimbursement).
Clinics provide the medication to patients.
Clinics submit claims for reimbursement, using the ForwardHealth portal or authorized forms which
indicate the rate the clinic usually charges for the medication.
Medicaid pays the clinics according to the Maximum Fee Schedule, not the clinics’ usual charge.
More than ten years later, the Department’s auditors assert that there exists a totally different
reimbursement rate and demand millions of dollars back.2
We question what authority exists for the Inspector General to retroactively lower the reimbursement rate
for services that have already been provided. What precedent does this set for all Wisconsin businesses
which provide services to the State of Wisconsin?
To be clear, WFPRHA does not dispute Wisconsin Medicaid’s handling of claims. Rather, we dispute the
Inspector General’s handling of audits—which are unsupported by Wisconsin Medicaid statutes,
regulations, and published Terms of Reimbursement.
WFPRHA believes that it would be worthwhile for the Legislative Audit Bureau to review the audits which
have already been performed by the Inspector General to determine whether or not their auditors applied
the appropriate standards and whether or not their preliminary findings have merit. Such a review will
demonstrate that Medicaid has not been overpaying family planning clinics by millions. Neither the
Inspector General’s preliminary findings nor the alleged concerns identified in other states provide a basis
to launch the industry-wide audit of Wisconsin health care providers requested by your colleagues.
Prior to making any decision about what audit scope may be appropriate, your committee may wish to
review the actual audit findings and the materials submitted by NEWCAP and Family Planning Health
Services in response to the audits. The materials are available at the Wisconsin Watch website in footnote
1, or through our attorney, Diane Welsh ([email protected]).
Representatives of WFPRHA would welcome the opportunity to discuss this matter with you. You can
reach us via email at [email protected] or via telephone at 608.348.9766 ext. 506.
WFPRHA Board of Directors
As of today’s date, the Office of the Inspector General has not issued a final determination of overbilling
in either audit. The preliminary findings letters included a request for repayment.