WFPRHA 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 requirements. 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. 1 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. Sincerely, WFPRHA Board of Directors 2 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.