As the need for public assistance programs – and the equal need to reduce government spending -increases, a variety of federal assistance programs are under tremendous pressure to maximize their limited resources. Key to this effort is the importance of ferreting out fraud, waste and abuse, and eliminating inefficiencies, while ensuring that these services are provided to those individuals that qualify to receive them.
That’s no easy task, given the patchwork of aid programs offered by a number of agencies, each with its own governing rules, qualification criteria and application process. Regrettably, the network of assistance programs has become mired in its own bureaucracy.
For citizens receiving support, they ought not be further burdened by having to steer through a maze of agencies, repeatedly having to provide the same information before finding help.
Simply naming the many human service agencies can be cumbersome; and navigating them is even more daunting. There’s Medicaid, and the Children’s Health Insurance Program (CHIP), which provides insurance to children whose families don’t otherwise qualify for Medicaid. There is the Supplemental Nutrition Assistance Program, (SNAP) which is separate from Special Supplemental Nutrition Program for Women, Infants, and Children(WIC). Then there’s Temporary Assistance for Needy Families (TANF), the National School Lunch Program, Head Start, Low-Income Home Energy Assistance Program (LIHEAP)… the list goes on.
Perhaps most notably is the Affordable Healthcare Act, more formally known as Patient Protection and Affordable Care Act of 2010 (PPACA) and more colloquially known as “ObamaCare,” which is bringing health insurance coverage to as many as 30 million additional Americans.
Streamlining services to reduce waste
Unfortunately, the myriad of health and human service programs have been largely compartmentalized, with each benefit agency having its own data collection system, eligibility requirements and program rules. Further, the technology that might streamline processing and combat waste is woefully inadequate; often unable to promptly access its own information, let alone match it against other content repositories.
This makes it impossible to validate client data that might already exist at other agencies or departments. The result is frequent re-entry of information causing processing delays, slowing response time and increasing manual labor. Unfortunately, these outdated systems are inflexible to modification and expansion from both a policy and technical perspective.
Further complicating the application for and administration of assistance benefits is the fact that federal aid programs are often administered at the state or local level. As services are “pushed down” to the state, the state and local agencies find themselves increasingly strained as they are hit by greater demands for services with diminishing budgets. Meanwhile, the states themselves offer their own assortment of health and human services programs, which complement, supersede or duplicate federal aid.
Helping to streamline processes to eliminate inefficiencies, would not only bring services more quickly to those that legitimately need them, but also cuts costs and exposes abuse.
Fraud and waste continues to plague assistance programs at all levels. In fact, a recent US House of Representatives oversight report, Uncovering Waste, Fraud, and Abuse in the Medicaid Program - citing numerous examples across multiple states-found that improper Medicaid payments alone are estimated to exceed $22 billion. The report found that taken collectively, fraud and abuse may amount to greater than $100 billion dollars in the Medicaid program alone. “The program has grown so large and so complex that it is unmanageable at the federal level and is highly vulnerable to waste, fraud, and abuse,” the report found.
Integrating Eligibility Data
Fortunately it’s not all bad news for social service agencies. These challenges actually present opportunities to update antiquated systems, reduce redundancies, minimizing abuse and providing better service to more recipients. Advances in decision analytic technology, the willingness to commit budgets to improvements, and federal funding for systems upgrades, is making this an ideal time to modernize eligibility processes.
Ready access to accurate eligibility data is key to bringing process efficiency and appropriate help to those in need. For example, leveraging public and private data sources against qualification benchmarks such as the Federal Poverty Level is just one way that data can be used to provide fair and consistent, real-time client screening. Data access and sharing across agencies and departments is also critical for catching fraud.
For agency case managers, the ultimate goal of an information system is to determine whether an applicant is eligible for benefits. The supporting infrastructure offers a simple eligibility verification decision. A case manager must ask, “Is this a valid application, and does this applicant qualify?”
These yes or no questions are ideal for today’s sophisticated data analysis and decisioning applications. Simple business rules can be matched against public and private data sources to verify the identity of applicants.
One such data source is the National Fraud Database that gives clients access to a repository of known fraud data contributed by their peers. This eliminates time-consuming individual industry searches and enables access to a nationwide consumer fraud records through a single access point. This early detection of identity theft can greatly reduce fraud losses.
Other data that can be used to validate eligibility and ensure accuracy include:
- Income – stated (or unstated) estimates of household income can be verified by matching income sources such as wages, alimony, or rental and investments income against various data sources;
- Assets – estimates of overall assets and available account verification or balance data;
- Address verification – matching applicant information against published data ensures information is entered into the system correctly the first time greatly improving benefit processing, communication and outreach.
Most social service agencies already well understand that streamlining their administrative, eligibility and verification processes will bring substantial benefits.
“A medium-size state can save between $15 to $38 millionin a typical integrated eligibility system if they plan carefully to make use of many common IT components,”said Tracy Wareing, executive director at the American Public Human Services Association, presenting at the APHSA Workgroup on Integration meeting. The problem hasn’t been a lack of desire to improve their data systems, the problem has been a lack of money.
Unfortunately government assistance programs have historically lacked the funding needed to invest in changes to their information handling systems. However, that is starting to change, as both states and federal government see the value-and ultimate cost savings-of modernizing data processes.
Despite political pressure to cut programs, there is still strong support for investments that make social programs more efficient and productive. Recent advances in information storage and retrieval systems now make it possible to access client data in real-time. This offers an opportunity to streamline services, verify eligibility and catch fraud before it happens.
For those in need, we now have the potential to create a “no wrong door” enrollment system where constituents are directed to the proper assistance and funds go to the people who need it most.
Barbara Rivera is president and general manager of Experian’s public-sector business in North America.