Clint Eisenhower
I hate to sound cliche, but it's genuinely true. We're stronger together and providing services when we tackle these issues together.
Jennifer Colamonico
You're listening to HMA Vital Viewpoints on Healthcare. Let's get started. Joining me today is Clint Eisenhower, a nationally recognized leader in Medicaid program integrity with more than 25 years of experience spanning state government. The center for Medicare and Medicaid Services, also known as CMS and now Health Care Consulting. Clint has helped shape federal Medicaid program integrity strategy.
He's led one of the nation's largest state Medicaid program integrity organizations, and he now advises states and health care organizations on strengthening oversight, improving performance, and navigating an increasingly complex health care landscape. Even more so with the rapid emergence of artificial intelligence. Clint, thanks for joining us today.
Clint Eisenhower
Thanks, Jen. I appreciate you having me, and I'm excited for the conversation.
Jennifer Colamonico
Well, it couldn't be a more interesting topic right now. Certainly popular topic. And your experience, just puts you in a really unique perspective here, I think. So you've obviously had state government experience. You've been at CMS in these roles. Now you're advising, you know, when we think about program integrity, also known as fraud, waste and abuse, depending on who's, talking about it.
What's the real job? How do you see what the real job is to be done here?
Clint Eisenhower
Yeah. It's, for me, it comes down to the mission, you know, it comes down to the right people getting the right services with the right providers and ultimately getting the right outcomes that they need, for their health care needs. I think that, a lot of times, you know, fraud, waste and abuse is set separately, but I've always considered it.
You mentioned program integrity, and I've also considered it enterprise risk management. You know, it's really about delivering services to people with good outcomes, and getting the bad actors out and keeping them out, you know, while ensuring access to care, good quality care and also reducing patient harm. So to me, that's the job. When you do program integrity, it's really about, you know, it's session and effective programs, that, you know, serve two purposes.
Obviously, that mission that I mentioned, but also protecting the taxpayers dollars.
Jennifer Colamonico
What do you think people outside the field or people reading about it in the newspapers? What do they typically misunderstand about what FHWa is?
Clint Eisenhower
It can be a very polarizing topic for sure, and I've seen that throughout my career. You know, again, working at various levels of government with different organizations. When I got into program integrity, it was it was a pretty natural fit because I do feel like eliminating you know, as much as you can. Fraud, waste and abuse is good for everyone.
Once you sort of break it down to what you're trying to accomplish, it's very hard to argue with stopping frog waste and abuse. So I think, you know, that's sort of, one way to shift the narrative is not fraud work being a bad word necessarily, but more so it's about, actually serving people and getting those bad actors out.
I think the other misconception, too, is that it's all fraud. You know, fraud leads to a sequence of frauds, only a very small part. Waste and abuse are far more prevalent and, far more costly and far more impactful on the quality of care. So I think that's another piece of it. And then the last thing I'll just say is, I've always felt like program integrity really is a team sport.
The federal government plays a role. States play a role. Health plans, providers, everybody, beneficiaries or members themselves plays a role. And so, you know, it's really there's always like a program integrity function. You know, there's a center for program integrity at CMS. There's, a medicaid fraud control unit and state government, you know, those are the functions that do this work.
But to me, it's always been more of a team sport. And if you work on it, across, you know, organizations, but also at the various levels of the health care ecosystem, it goes much better and, you know, ultimately achieves the goals. So I think those are probably the, you know, the big three is, you know, let's not let's not make it, a negative topic.
Let's make it a, you know, a means to an end of, really serving people in the right manner.
Jennifer Colamonico
It's such a classic example of, you know, communication strategy. Right? Because you're right. I mean, everybody anybody who engages with the health care system at all, we all know there's waste. We know it, we see it. We feel it in our own, you know, experiences with using the system. And, you know, we also all probably are happy to hear when, people crack down on fraudulent act or that just this morning, something in the state of New York, you know, some Medicaid fraud happening in the Buffalo area, right?
You say, okay, good job. This is, you know, yeah. But it seems to be, you know, also used as like a finger pointing exercise fraud. And we're using it, you know, kind of, I don't know if, like, on offense, I mean, we want to be on offense, but we're also using it to kind of paint people with a brush.
So maybe talk a little bit more about that distinction, you know, between fraud and waste because I think it's easy to talk about somebody else's fraud. But when you know you're the provider or you're doing something.
Clint Eisenhower
Sure.
Jennifer Colamonico
It may not feel like that.
Clint Eisenhower
Yeah. I mean, it's really it is the finger pointing. Definitely happens. You know, fighting fraud, waste and abuse is really hard. It's one of the harder jobs, I think, in, you know, government. And because at the end of the day, you know, you're going to take some kind of action potentially against somebody. And, everybody sort of agrees with addressing fraud, waste and abuse until it affects them, you know, and they're sort of wrapped up in it.
And so, it's I think that sometimes contributes to, you know, some of the unpopularity when you talk about fraud, waste and abuse. When I was working for the Pennsylvania Department of Human Services, you know, a member of my leadership team said to me, run it like a business, which I thought was a really interesting concept.
You know, at that point had been in government for about ten years. And then after I have somebody saying to me, you know, run it like a business and, you know, really what they meant by that was you have finite resources. You know, we have a finite budget, something that's really funded, some of it's state funded, you know, and and especially with the fiscal environment, you know, states maybe not wanting to raise taxes, you know, but having to deal with federal mandates, you really have to watch the purse strings.
And, you know, Pennsylvania, I think at the time had like a $30 billion budget, huge amount of money. But you could, you know, spend it all pretty quickly on those programs. There was yeah, there was to 2.2 million beneficiaries at the time for expansion. It's like 3 million now I think, in Pennsylvania. But so, you know, for me, you know, when you have finite resources, that's when you really lean into the to the waste aspect of it and make sure that your programs are running efficiently and effectively.
One of my favorite projects that I worked on, it was called like a high cost case review, and it was really looking at, benefits, waiver services and Medicaid that were of a certain dollar amount. And it was, it started out as a kind of a cost containment initiative. But what happened was, we worked with, the beneficiaries themselves, the providers, the families, the caseworkers, you know, everybody who was involved in somebody's care to look at their case mix.
Because what we were seeing was you know, over a five year period, the cost of their care rose every year. You know, the number of units, the services rose every year. But they weren't getting better and they weren't getting the outcomes. And so we decided to look through each of those care plans. And the result of it achieved two great things.
It did cut some cost, but it also, gave people better outcomes. In some cases, people's, you know, costs went up because they needed additional services or different services. And in other cases it went down. But it you know, really it really did a lot of good things around like, you know, beneficiary satisfaction. And so it shifted from sort of this, you know, program integrity initiative to just getting people the right, the right services.
The last thing I'll add to this, you know, is, you know, we spend a lot of time in, you know, the various, health care environments on, you know, the pay and chase aspect of it, you know, and there's a lot of, a lot of time that's spent on investigations and, you know, finding these bad actors and trying to recoup it.
But interestingly, you know, a lot of the money that's spent on fraud, waste and abuse is on prevention. You know, the, member eligibility systems provider screening the MMI. And so the Medicaid management information systems that pay the claims, you know, I like to call those like the three front doors. And I can talk about that certainly more.
But, you know, that's where the money goes. And yet, you know, these bad actors still get in and then you're stuck in this pay and chase, time consuming cycle.
Jennifer Colamonico
Talk a little bit more about how waste actually harms patients. Fraud you could think of okay, that's a bad thing. You could see how that harms patients. But waste, you know, how does that have a direct correlation to kind of how patients experience the system. And you know, why is that a good thing for patients to get rid of waste.
Clint Eisenhower
Sites and health plans. You know, they have a certain provider network. And so, you know, it's very simply, if a provider is spending time on a beneficiary who's not truly eligible, right? Services, you know, it's not that that person doesn't need access to health care, but, it can create issues, you know, with the billing and the coding and things like that.
And it's just all about inefficiency. You know, we all have experience long wait times in health care settings and, you know, or if you're, you know, trying to treat a condition and you jump from provider to provider, there's, you know, inefficiencies there as well. Obviously, you know, managed care, an HMO is or, you know, an attempt to try to coordinate some of that care.
It's probably even more so to me about the time, not even the dollars every, every, you know, minute of time, you know, you spend, doing something, you know, for, you know, whether it's a provider that's not truly, you know, eligible to provide services or a member who's not eligible receive services, you know, every minute of time is spent taking away from somebody who does need the services.
And so that that waste creates inefficiencies. And then, I mean, I think the other piece, too, is, you know, again, I mentioned some of the Pennsylvania statistics. I mean, Pennsylvania Department Human Services is a huge agency, you know, 18,000 employees. And I gave some of the budget, you know, numbers as well. But, you know, just inherently, you know, some of this work is siloed.
So I might be sitting there as a program integrity director, but I have to work with the eligibility director and the Medicaid director and, and the health plans, the macOS, the providers themselves, you know, really to get to the root causes of the vulnerabilities. And I think I think that's where, you know, I saw just doing program integrity, the waste manifest, I'd be signing letters for overpayments, you know, for, you know, 40 to $100, not not a lot of money.
And I knew that, you know, took a lot of time to do that, you know, investigation and review. But the result of it wasn't a lot. So it costs a lot more to do it. But if I, you know, find the same issue, keep cropping up, I'd start to say to myself, okay, what's going on here? Why does this keep happening?
There's a vulnerability somewhere else in the process. There could be a policy that's an issue or a process or something in a system, even organizational structures. And so getting to that root cause, I think is another, another huge contributor to, you know, the waste aspect you have to figure out instead of just continuing to repeat the cycle, okay, what's really happening here and get to that and attack it as quickly as possible.
Otherwise it just continues to permeate and over time and then, you know, that slows down to, you know, to the to the people that are receiving the services, you know, whether it's, you know, coverage that they have or coverage that's inside.
Jennifer Colamonico
How do you tease out that, you know, wastes from fraud? I mean, there's, you know, and when you think about I'd like to start to talk about technology in a moment here and kind of pivot towards these, you know, how we how we are fixing this. But, how do you know when something is truly fraud or just waste?
That is a product of a system that, you know, has tremendous inefficiencies? You know, if we have record systems that aren't talking to each other and the ability to share, I mean, you know, how much of it is actually fraud and waste and how much of it is just, you know, we need to make these systems work better with fraud.
Clint Eisenhower
I mean, there's some clear, you know, willful intent to, to commit the fraud. And so usually it manifests as somebody just clearly breaking the rules. And, you know, when you do data analytics, you look for outlier and aberrant behavior. You look for, you know, sort of data anomalies that, somebody is, you know, treating more than humanly possible number of patients in one day or doing something to their you know, provider specialty that you know, they couldn't accomplish in a 15 minute time segment.
So there's things like that. But, I mean, I, I genuinely believe that, I believe in the good, you know, if people and people want to do the right thing and they're in this for the right reasons, and people need the help. And there's, you know, by large, most providers, want to do a good job and health plans as well.
And so, you know, for me, it's about, you really getting kind of clear on what is the waste piece of this, you know, fraud especially you do state program integrity fraud. You know, you kind of hand it over to like, law enforcement. And if it's criminal or you handle the civil side of it and, you know, you issue an overpayment letter.
And so, you know, once there's that sort of, you know, that indicator of fraud plays out to be actual fraud. There's mechanisms in place to deal with it. And it sort of like a finite end point. But the waste piece of it, there's really no finite end point. You have to first figure out what the source of the waste is, and then you also have to figure out the right intervention.
So one thing we did at CMS, we focused we had a provider continuum like this is more Medicare focused. I've, you know, been largely Medicaid in my career, but Medicare as well, a provider continuum. Not every provider needs an audit. You know, you can't audit every provider. Most just need education and technical assistance, and you can accomplish a lot with that.
You can accomplish a lot with just, hey, you know, you're not coding properly or you're not billing properly. So it's figuring out not just where the vulnerabilities is, but then also the right intervention. And, a big part of why I went to CMS was it was a newly created, state. It was called the State Liaison Staff.
So I'd spent you know, 15 years of Pennsylvania state government, CMS the center for Program Integrity wanted to create, more like a state partnership, versus kind of traditional oversight. A lot of the things we're seeing now and that organization still exists. But it was meant to be. Also, you know, when I talk about a provider continuum, same thing with the states, like help, help the states.
And so really focusing on what education and technical assistance you can provide, you know, as a federal government agency to the states and then helping states figure, okay, what providers do I need to actually audit or investigate? But by and large, most of them just need education and technical assistance. And so I like to call it I mean, it's again I use enterprise resource management.
It's really like okay what is going to move the needle here and what's going to be the most effective.
Jennifer Colamonico
So what have you learned, in all of this that, that, you know, seems applicable to delivering better care, right. Because I think leaving fraud and abuse to the side because clearly those are, you know, bad intent, I think waste you know, there's a lot of a lot of room for discussion there. And over time, I mean, as you're talking about pattern, do you see patterns?
You know, one would think you sort of translate that into then policy correction. Right? It's not working this way. We're still wasting money this way. You know, how do we how do we stop that waste? And I and, you know, obviously, as you referenced, managed care is one way to do that, to kind of restrict or approve or try to create pathways for getting care.
But, you know, is there a cyclical kind of feedback loop there, or are we kind of taking lessons from waste and translating that into either federal policy or business, you know, policy with plans?
Clint Eisenhower
I had a great team in in Pennsylvania and CMS that I've been really blessed to be able to work with some, you know, great folks who looked out for the greater good of the program and, you know, goes back to that sort of program. Integrity is a team sport. You know, you might have situations where you see a vulnerability in program integrity, but you see it requires a policy change and you go to talk to, you know, the folks that lead the policy aspect.
And, you know, there's a disagreement about the, you know, the vulnerability, and you have to negotiate that to some extent. And so, some of the work that I'm doing currently with clients is, is all about that is it's about, okay, you're in program integrity. How do you get a seat at the table in program and benefit development.
So you can in, you know, implement these, measures at program development before the program launches. And then, you know, I've done that many times throughout my career where it's like, okay, we're going to start a new program. Let's think about the program integrity, vulnerability now based on what we know. But, you have to you have to build, you know, kind of consensus.
You have to be very much, you know, an integrator. And I think the states that and, you know, states and health plans that do this the best are the ones that, you know, Seybold, see the bigger picture and, you know, build those relationships. I had an amazing Medicaid director in Pennsylvania that I worked very closely with. And, you know, we identified some things that needed to be done.
And, her and I set out to do that, and we brought in the managed care organizations, talk to them, you know, made modifications to the contracts and, you know, everybody sort of, I think got what they wanted at the end of the day, which was, you know, good, good programs. And so that's what I always recommend is, you know, build that, like break down those silos within an agency, right.
And, and even break down those silos between state and federal government. Like, this goes so much better when we're all in it together for the right reasons. I hate to sound cliche, but it it's genuinely true. We're stronger together in providing services when we tackle these issues together.
Jennifer Colamonico
Let's talk about technology. Because, you know, everybody, is trying to find and establish the ways that AI is, is going to be helpful and in health care and certainly we expect there are many. But how are you seeing AI improve program integrity work. What role is that playing. And, you know, are there places where it's perhaps a risk.
Clint Eisenhower
I think in, you know, like experience. I mean it has evolved quicker than we can blink and that's on our side. But it's also on the fraudsters side, you know. So you know, they can they can use it much more easily to, you know, generate fake, you know, data, fake people, fake profiles, etc.. But I think that, you know, a good use of AI is to help you get to the risk more quickly.
You know, when you're thinking about, like, health care claims, you have thousands and hundreds of thousands of claims and stuff, and you have to, you know, review them quickly. You know, you have these large, you know, member populations, these large provider ecosystems. So I think a good use of, of AI is to sort of narrow down the funnel and, you know, using it to, target your risk.
You know, I, I've mentioned a few times, you know, finite resources to provide services, but it also goes the same way with stopping the fraud, waste and abuse. There's finite resources to do that. And you can only do so many, you know, audits and reviews. So to me, a good use of AI is to, get kind of quicker to the potential risks.
But then humans to step in and adjudicated. I just, you know, I don't think we can, I don't think we can automate, you know, that kind of final human in the loop review where it's like, okay, I have all my data, I have all my information, I have all, you know, kind of this analysis done, you know, is this fraud, is this waste is is abuse.
I still think there's, you know, a well trained AI that looks at that and then also decides what the mitigation strategy is, you know, and you could use AI to, you know, take a theory and say, okay, if this is my issue, do I need a policy change? Here's my policy. You know, here's my process. What's broken here?
But, you know, at the end of the day, someone has to decide because I just I don't think, you know, AI is evolved enough to understand the policy nuances. And I it's not just I hear that too, you know, about, analytic systems that do claims review. You know, there's a lot of companies that have great products that do a really good job.
And there's a lot of great people in, you know, government and health plans and the ones that do analytics work and can really identify these things quickly. But there's always that sort of like program specific nuance, whether it's a federal policy or a state policy or frankly, the, you know, the clinical AI, my work, my wife's a nurse practitioner or, you know, she can have all the textbook, you know, training she wants.
But when you're with a patient or a member, it's sort of that on the spot judgment. So that's how I recommend it's used. It's, it's gets you, you know, it gets you quicker, but you go into it knowing, you know, enough to determine whether the AI is effectively doing what you need. And then when you need to step in.
Jennifer Colamonico
Yeah. So what, you know, what constitutes a really strong Medicaid program? Integrity organization.
Clint Eisenhower
To me. You know, the states that do the best are the ones that, you know, open the aperture and look at the whole ecosystem. They have that sort of continuous feedback loop. And so if you think about your entering any kind of program, you fill out something, you know, some kind of application to get services, to provide services to be paid for services.
So you provide information, you have to validate that information. You know, make sure it's number one, it's accurate. But then number two that it fits the programmatic requirements. So for me you know, it's always been sort of the states that look to the earliest part of the process. You know, it's possible to identify those bad actors and keep them out.
Or if they do somehow get in, they stop them. And, you know, maybe I'm a little bit biased because I've done, you know, largely program integrity. But I do think program integrity has a very valuable seat at the table. And when it's seen as, a helper to accomplishing the mission, it goes a lot better than if it's seen as a barrier.
Talk a little bit more about the kind of the state CMS relationship.
Clint Eisenhower
You know, the federal government funds these, you know, Medicaid programs, right? So they so, you know, they have the responsibility of doing oversight. You know, they send the money to the states. And if issues arise, they're going to go talk to the states about it. And, you know, the states have health plans. I mean, it slows down a little bit.
And then the plans have providers. I spent three years at CMS and as I mentioned, I went there to work with states. And, I thought it was a really cool concept. You know, it's like, okay, you take everything you learn in one state and work with all 56 states and territories. And I and I knew a lot of, you know, the program integrity folks in other states because we work together, you know, states like to talk about what's working, what's not working.
They have a lot of the same contractors, you know, so they talk about best practices. But when I went to CMS to do this work, you know, it was really kind of all in on that technical assistance and education. And so, and again, these programs are still in effect today. There's something called the Medicaid Integrity Institute that CMS runs where they provide federally funded free training to states for program integrity.
Every year, you know, at the time when I was doing that, we had about 23 courses a year. They were 2 to 3 day courses. It's about a $4 million program. We were helping the states. It wasn't like audit and oversight. We were teaching them, you know, managed care and providers, screening and enrollment and member eligibility, third party liability, data analytics, all these good things that go into program integrity.
So I was very much on the side of working with states. And I think that, again, just like I'd say it's a team sport within a state or within an organization, it's like it's a team sport between state and federal government. You know, to this day, I still reach out to friends, you know, that are in states and talk to them.
When I see something on LinkedIn, like a best practice, like, wow, that's really amazing what you're doing there. Yeah. Tell me more about that. Or kind of connect you with another, you know, state or another client to try to, share some of those things because they're interested in doing you know, something similar to what your state is doing.
I always I guess I'll just try to summarize that, you know, it's sometimes it's hard to get to the right place in the federal government and know who to go to to get answers and, you know, to get consistent answers depending on who you're talking to. And so, I know CMS, you know, has spent a lot of time trying to fortify those areas to partner with states.
And so it's not all of the, you know, kind of, you know, what you see on the news, you know, the unfortunate, you know, just disallowance and deferrals and, you know, clawing money back. But there's also pieces that if you're willing, you know, as a state to try to do things differently. You can work with the federal government.
I've seen it. You know, when I was in the federal government, I've seen it even here at FMA, where, you know, I've actually facilitated conversations with, you know, state and federal government where they're talking together and, you know, state can say, hey, what are you doing in Medicare that's working really well? Or, what state's doing really a great job in data analytics.
And so to me, when the states and feds work on this, collaboratively, I think it goes, it goes better for both parties.
Jennifer Colamonico
So there's a question that we like to ask on every episode. And as somebody who's been in it for this long, you have a unique perspective. On, you know, what it takes to do this work. And so, if you had a magic wand and you could wield it to change one thing in health care that would improve care, that would reduce waste, that would kind of, you know, move the needle here.
What would you fix first?
Clint Eisenhower
Being able to eliminate the fraud, waste and abuse. I mean, it's sort of a personal topic, you know, for me. And I think maybe that's why I lean more into the waste, you know, versus the fraud. I mean, you know, we all we all have stories about, you know, people who have been victims of fraud. And it's terrible and horrible, but, you know, the waste side of it.
I mentioned my wife a little bit, you know, she's had some, some, some health issues and I've sort of and she's a health care provider. I've sort of, you know, watched her bounce from, you know, provider to provider, you know, across state lines and within state, you know, and, just not get the answers over, over extended periods of time.
You know, without getting into too many details, it's been a struggle at times, you know, takes a toll on you know, her personally in our in our family. And so, I, I can't help but wonder, you know, if some of that, lack of answers is just because, you know, system's so overwhelmed and, you know, because you're spending so much time dealing with, you know, the fraud and, you know, and then the waste kind of manifest as well, you know, does that is that a big blocker to health care outcomes?
I think I think it is, you know, and and I think I think we all probably have, you know, stories like that, you know, not just even now, but even in my childhood, you know, coming from kind of a, you know, working, you know, lower middle class family, you know, insurance was a big deal and access to care was a big deal.
And, you know, it's yeah, it's I broke my pair of glasses. I wasn't able to get a new pair. You know, I had to put some tape on it and stuff. And so I think the magic wand would just be trying to get rid of as much of the, you know, the aqua as possible because, it's just such a blocker to, you know, quality outcomes.
And I guess, I guess we've all, you know, experienced situations where, gosh, you have somebody who's just searching for answers and trying to get better and you just can't. And it just takes so long and so much time and energy and self-advocacy and things like that. So I don't know if that's the answer. You know, if you thought it would be good, but I it's certainly it's kind of what, you know, what fuels me on the personal side is just, watching family members, you know, need, need care and and help and, you know, the struggle to to get better.
Jennifer Colamonico
Well, it's magic. So that would be that would be magical. So that's a fair answer to the question. I guess. My maybe my follow up is, do you believe that technology is going to get us there? You know, how optimistic are you that we have now tools that are going to get us there faster?
Clint Eisenhower
Again, I use it more of a program integrity, context, but even, even with diagnosing somebody, you know, you're kind of in the moment, you know, what? You know, but there are, you know, tools. There are, you know, research and scientific tools that can help you with diagnosis and things like that. I mean, and we use some of those tools, you know, personally in my family.
And so, I think it starts how do I say this artfully? I think it starts with like, the human, you know, curiosity and desire to fix something. Right? And or to help somebody get better or to help them achieve whatever it is they want to achieve. And then you use technology as an enabler. So I think as long as you know, the human spirit is there and the desire to to do the right thing and to improve that, the technology can certainly, you know, speed up that process and enable it.
But, you know, technology without that human aspect, is just technology. And I think that it's really important that, you know, at the end of the day, these are real people, you know, getting help, real people providing help, and they are real people ultimately deciding what the outcome is going to be. So I love technology and I think it's a great enabler.
You got to have that human curiosity and that desire for to, you know, to get the outcomes and the answers that you're seeking.
Jennifer Colamonico
That's a great answer. It's really been a pleasure talking to you. Thank you for, for giving us time today and for all the work that you're doing.
Clint Eisenhower
Thank you so much for having me. I really enjoyed it as well. And, look forward to the next one.
Jennifer Colamonico
Thanks.
This episode of Vital Viewpoints on Healthcare is sponsored by HMA Information Services. HMAIS is a subscription based service that provides state level data on publicly sponsored programs like Medicaid from the latest managed care enrollment, market share, and financial performance data to up to date RFP calendars, and state by state overviews. HMAS has all the information you'll need to power your initiative to success.
This podcast was produced by myself, Jennifer Colamonico along with Tiffany McKenzie in collaboration with our guests. The content is the property of Health Management Associates.
