An Act To Improve Program Integrity Activities within the Department of Health and Human Services
Maine Legislature, Session 127, LD 0421
Committee: Health and Human Services
Sponsors: GATTINE, LIBBY, BECK, DION, FARNSWORTH, FOWLE, GIDEON, GOLDEN, SANBORN

Legislative Document 
No. 421 
H.P. 288 
House of Representatives, February 12, 2015 
An Act To Improve Program Integrity Activities within the 
Department of Health and Human Services 
Reference to the Committee on Health and Human Services suggested and ordered printed. 
ROBERT B. HUNT 
Clerk 
Presented by Representative GATTINE of Westbrook. 
Cosponsored by Senator LIBBY of Androscoggin and 
Representatives: BECK of Waterville, DION of Portland, FARNSWORTH of Portland, 
FOWLE of Vassalboro, GIDEON of Freeport, GOLDEN of Lewiston, SANBORN of Gorham. 
Be it enacted by the People of the State of Maine as follows: 
Sec. 1.  22 MRSA §§20 and 20-A are enacted to read: 
§20.  Report of department’s efforts to investigate MaineCare program integrity 
The department shall design a comprehensive and well-coordinated system to ensure 
that public funds are well managed and dispensed for the purposes for which they are 
appropriated and deliver the best value for the people that they serve. 
The department shall report annually by February 15th to the joint standing 
committee of the Legislature having jurisdiction over health and human services matters 
and the joint standing committee of the Legislature having jurisdiction over financial 
affairs regarding MaineCare program integrity efforts of the department, including efforts 
to investigate and prosecute fraudulent incidents or practices.  The report must contain the 
following information: 
1.  MaineCare programs.  The following baseline information for the prior year for 
MaineCare programs: 
A.  The total unduplicated number of households, children, persons with disabilities 
and seniors receiving assistance under each MaineCare program; and 
B.  The total MaineCare program expenditure in general funds, federal allocations 
and any special revenue funds; 
2.  Description of program integrity efforts of department.  A description of the 
department’s efforts under this section and under chapter 855, including any efforts made 
in cooperation with federal agency partners in investigating and prosecuting fraudulent 
claims and overpayments to providers, vendors and retailers, including: 
A.  The number of staff investigating cases; 
B.  The number of cases opened, investigated and disposed of; 
C.  The sources of the cases opened; 
D.  The dispositions of the cases closed; 
E.  The number and amount of fraudulent overpayments recovered and fines or 
penalties actually imposed, expressed in absolute dollar values and as percentages of 
all funds spent in each program; 
F.  The amount of recoveries of fraudulent claims reclaimed by the Federal 
Government; 
G.  All costs associated with all activities related to discovering, investigating and 
prosecuting cases in which fraud was alleged, whether or not fraud was determined to 
exist, for each program, both in absolute dollar values and as percentages of each 
program; 
H.  The average length of time to recover fraudulent overpayments and fines or 
penalties imposed from the time cases are opened until the time overpayments and 
fines or penalties are repaid in full; 
I.  The amount of fraudulent overpayments determined as uncollectible; 
J.  The amount of fraudulent overpayments recovered by type of offender; 
K.  The amount of fraudulent overpayments recovered by a business unit within the 
department's audits and program integrity activities group; 
L.  The number of MaineCare providers, retailers or vendors, by type, that are 
terminated from participation or otherwise sanctioned from participation in public 
programs as a result of program integrity activities;  
M.  The amount of all recoveries of fraudulent overpayments received as a result of 
multistate litigation against pharmaceutical companies or other providers; and 
N.  The dollar amount, by provider type, of any overpayment recoveries; 
3.  Referrals to Attorney General.  The status of cases referred to the Attorney 
General's health care crimes or other unit or other law enforcement entities and the 
number and disposition of those cases and the amount of overpayments recovered, all 
detailed on a per case basis, as long as the information disclosed conforms to the 
requirements of Title 16, section 804 and does not compromise the investigation or 
prosecution of a case; 
4.  Performance and activities of vendor, contractor or other program integrity 
unit used by the department.  If the department uses a vendor, contractor or other 
program integrity unit to assist in the identification and recovery of overpayments, a 
description of the performance and activities of the vendor, contractor or other program 
integrity unit used by the department.  The report must include what the scope of the 
vendor's, contractor's or other program integrity unit's activity is, what payments have 
been made to the vendor, contractor or other program integrity unit, how many cases have 
been opened, how many overpayments have been recovered and any other benefits from 
the vendor's, contractor's or other program integrity unit’s involvement; 
5.  Department's participation in federally mandated program integrity efforts.  
A description of the department's participation in federally mandated program integrity 
efforts, including the federal Centers for Medicare and Medicaid Services Recovery 
Audit Program and Payment Error Rate Measurement program, and the impact of this 
participation on department resources and money recovered and the number of providers 
sanctioned and referrals made as a result of this participation; 
6.  Results of federal audits.  The results of any federal audits of the department's 
program integrity activities, including weaknesses identified and best practices identified; 
7.  Defects, deficiencies or weaknesses in department systems.  A description of 
any known defects, deficiencies or weaknesses in any systems managed or used by the 
department that resulted in the improper or inaccurate payment of claims or benefits, 
including but not limited to the Medicaid information system, provider enrollment system 
and eligibility determination system.  The report must include an estimate of the financial 
impact of these issues and a timeline for remediation and a description of any known 
defects, deficiencies or weaknesses in any systems managed or used by the department 
that have been corrected and an estimate of the cost of and any savings from these 
corrections; 
8.  Planned investments in technology.  A description of any investments in 
technology planned by the department to improve efforts to prevent improper payments; 
and 
9.  Policy changes or improvements.  A description of any policy changes or 
improvements implemented by the department to improve the accurate payment of claims 
and benefits. 
§20-A.  Report of department’s efforts to investigate program integrity made under 
the Temporary Assistance for Needy Families and food supplement 
programs 
The department shall design comprehensive and well-coordinated systems to ensure 
that public funds are well managed and dispensed for the purposes for which they are 
appropriated and deliver the best value for the people that they serve. 
The department shall report annually by February 15th to the joint standing 
committee of the Legislature having jurisdiction over health and human services matters 
and the joint standing committee of the Legislature having jurisdiction over financial 
affairs regarding the program integrity efforts of the department in the Temporary 
Assistance for Needy Families program and the food supplement program under section 
3104, including efforts to investigate and prosecute fraudulent incidents or practices.  The 
report must contain the following information: 
1.  Temporary Assistance for Needy Families and food supplement programs.  
The following baseline information for the prior year for the Temporary Assistance for 
Needy Families and food supplement programs: 
A.  The total unduplicated number of households, children, persons with disabilities 
and seniors receiving assistance under each program; 
B.  The average monthly benefit for each program in general funds, federal 
allocations and any special revenue funds; and 
C.  The total program expenditure in general funds, federal allocations and any 
special revenue funds for each program; 
2.  Description of program integrity efforts of department.  A description of the 
department's efforts under this section and under chapters 851, 1053-B and 1054-A, 
including any efforts made in cooperation with federal agency partners in investigating 
and prosecuting fraudulent claims in the Temporary Assistance for Needy Families and 
food supplement programs, misuse of public benefits instruments investigated pursuant to 
Title 17-A, section 905-C and vendor and retailer fraud, including: 
A.  The number of staff investigating cases; 
B.  The number of cases opened, investigated and disposed of; 
C.  The sources of the cases opened; 
D.  The dispositions of the cases closed; 
E.  The number and amount of fraudulent overpayments recovered and fines or 
penalties actually imposed, expressed in absolute dollar values and as percentages of 
all funds spent in each program; 
F.  The amount of recoveries of fraudulent claims reclaimed by the Federal 
Government; 
G.  All costs associated with all activities related to discovering, investigating and 
prosecuting cases in which fraud was alleged, whether or not fraud was determined to 
exist, for each program, both in absolute dollar values and as percentages of each 
program; 
H.  The average length of time to recover fraudulent overpayments and fines or 
penalties imposed from the time cases are opened until the time overpayments and 
fines or penalties are repaid in full; 
I.  The amount of fraudulent overpayments determined as uncollectible; and 
J.  The amount of fraudulent overpayments recovered by type of offender; 
3.  Referrals to Attorney General.  The status of cases referred to the Attorney 
General's health care crimes or other unit or other law enforcement entities and the 
number and disposition of those cases and the amount of overpayments recovered, all 
detailed on a per case basis, as long as the information disclosed conforms to the 
requirements of Title 16, section 804 and does not compromise the investigation or 
prosecution of a case; 
4.  Performance and activities of vendor, contractor or other program integrity 
unit used by the department.  If the department uses a vendor, contractor or other 
program integrity unit to assist in the identification and recovery of overpayments, a 
description of the performance and activities of the vendor, contractor or other program 
integrity unit used by the department.  The report must include what the scope of the 
vendor's, contractor's or other program integrity unit's activity is, what payments have 
been made to the vendor, contractor or other program integrity unit, how many cases have 
been opened, how many overpayments have been recovered and any other benefits from 
the vendor's, contractor's or other program integrity unit's involvement; 
5.  Department's participation in federally mandated program integrity efforts.  
A description of the department's participation in federally mandated program integrity 
efforts, including the federal Centers for Medicare and Medicaid Services Recovery 
Audit Program and Payment Error Rate Measurement program, and the impact of this 
participation on department resources and money recovered and the number of providers 
sanctioned and referrals made as a result of this participation; 
6.  Results of federal audits.  The results of any federal audits of the department's 
program integrity activities, including weaknesses identified and best practices identified; 
7.  Defects, deficiencies or weaknesses in department systems.  A description of 
any known defects, deficiencies or weaknesses in any systems managed or used by the 
department that resulted in the improper or inaccurate payment of claims or benefits, 
including but not limited to the Medicaid information system, provider enrollment system 
and eligibility determination system.  The report must include an estimate of the financial 
impact of these issues and a timeline for remediation and a description of any known 
defects, deficiencies or weaknesses in any systems managed or used by the department 
that have been corrected and an estimate of the cost of and any savings from these 
corrections; 
8.  Planned investments in technology.  A description of any investments in 
technology planned by the department to improve efforts to prevent improper payments; 
and 
9.  Policy changes or improvements.  A description of any policy changes or 
improvements implemented by the department to improve the accurate payment of claims 
and benefits. 
Sec. 2.  Existing resources.  The requirements of this Act must be accomplished 
within the existing resources of the Department of Health and Human Services. 
SUMMARY 
This bill requires the Department of Health and Human Services to report annually by 
February 15th to the joint standing committee of the Legislature having jurisdiction over 
health and human services matters and the joint standing committee of the Legislature 
having jurisdiction over financial affairs regarding actions taken by the department to 
investigate program integrity under the MaineCare, Temporary Assistance for Needy 
Families and food supplement programs, including the amount recovered, the cost of 
those investigations and prosecutions, the number of personnel working on the 
investigations, the status of cases referred to the Attorney General's office, a description 
of the performance and activities of a vendor, contractor or other program integrity unit 
used by the department to help recover overpayments, a description of the department's 
participation in federally mandated program integrity efforts, the results of federal audits, 
a description of defects, deficiencies or weaknesses in department systems, a description 
of planned investments in technology and a description of policy changes or 
improvements implemented.  The bill specifies that information disclosed by the Office 
of the Attorney General for the purposes of the annual report from the Department of 
Health and Human Services on investigations and prosecutions of false claims made 
under the MaineCare, TANF and food supplement programs on the status of cases must 
conform to the law on intelligence and investigative record information and may not 
compromise the investigation or prosecution of a case.  The bill also specifies that the 
requirements of the bill must be accomplished within the existing resources of the 
department.