one hook in the water or you can put five hooks in the water and you may only catch one fish but you are going to catch more more often if a rack decides they are going to grab 20 different cases and they hope they win ten of them that's better than just grabbing ten of them and if it's close, go ahead and just grab that file and keep moving from there and we may win it, we may not win it. that's helpful to the rac in their contingency fee. that's certainly not helpful to the provider to go through the process. with that, i recognize dr. gosar. >> do you have any differential in your facts in terms of small providers, large providers, in overturn rates? >> i don't think the data differentiates, in terms of appeals data, i'm not aware of differences. i think the point i made earlier is that we do have different requirements of the contractors when they look to audit a

smaller provider versus a larger one. there is different medical record request requirements to try to limit that burden that is being placed especially on the smaller provider. >> it would be very interesting now -- particularly i represent rural arizona and so i would like to see some type of movement to try to make that accountable. you know, when you said an overturn rate with part a what about part b? >> you know, i'm actually not aware of -- i don't have the figure in front of me. we can actually connect with your office if that's okay to get you a part b overturn rate. >> i think that's very important. because those part b aspects are institutions and not individual providers. would you agree? >> i think the part -- let me just make sure i heard you correct, sir. i believe the part a claims are the ones that tend to be more institutional, the hospitals. and then the part b claims can tend to be individual providers or groups of providers. >> okay. miss king, from your oversight aspect, do you see maybe a change that you would recommend

for methodology instead of, you know, looking at a provider as being guilty in an aspect, kind of an atmosphere like that? do you see a better way of handling this? >> i don't actually think that the -- that the post-payment review starts off with the provider is guilty. i think it's not -- it's not a criminal matter. it's a matter of a -- either an overpayment or an underpayment, and i do think that cms has a responsibility as stewards of the trust funds to make sure that claims are paid properly and as part of that i think they need to do as much as they can effectively on the prepayment side but i also think that they need to look at the post-payment side. but i also think that they need to look at the post-payment side. that being said, we have found some instances in which the requirements are posing

administrative burdens on providers and we have recommended that cms reduce not the requirements, but the differences across contractors so that providers have a better understanding of what they are required to do. >> from the standpoint of that process, dr. agrawal, is there a way that we could actually identify maybe frequent flyers? do we have a frequent flyer list? i mean, state boards kind of do this. we're kind of replicating something that state boards do. >> well, i think we take a different approach. so, you know, the spectrum of program integrity is long and there are folks on one side that are totally legitimate providers that are trying to abide by our rules that are honest and they are the vast majority of providers. on the other side, a much

smaller subset are potential criminals or people that are perhaps trying to rob the program. so we do take, you know -- i would argue that the various approaches that we have to overseeing the program integrity issues do try to take into account where our risk really lies. and i think part of why we can take an audit base or post-pay approach for the vast majority of providers is because they are legitimate and an audit is a reasonable approach for them. we do take a much more kind of risk-based approach on the fraud side that really can ratchet up the intensity of how we look at a provider based on findings from audits. i think that's really appropriate for providers that are pushing the line, potentially of even committing criminal activities. we try, on the other side of the house, to take a much more fact-based approach. we look at issues that are big national issues where we know there are improper payments and then we'll do deeper analyses to determine which providers to look at, but it tends to be focus ds on where our improper payments are occurring. it's not ratcheting up on a single provider.

>> but wouldn't be it more efficient in regards to looking -- having some type of a profiling aspect? you know, in state boards, i mean, you have a list of the -- most of your problems are with 10% of the population? >> right. i would remind you that state boards are dealing with the most difficult of cases. they're the ones on the right side of the house where these are providers that are committing potentially criminal or negligent activity. they are dealing with the worst actors. again, we do do that with a similar set of actors. i think what we are looking at perhaps, again to try to decrease the potential burden from these audits, is not ratcheting up, but perhaps looking at solutions that might ratchet down. as providers get audited and it turns out their claims are substantiated, perhaps we could audit them less. that's a solution that we are

looking into implement. >> can i follow up on that as well? as of when? that is one of the recommendations that hovers out there. how does someone prove, basically, i'm a good actor, and don't get someone constantly coming in to check them all the time? >> there are a number of slugs we're looking at. as someone pointed out earlier, rac is currently in a paused state where we're working on the next round of procurements. as part of that procurement activity, we're taking into account a lot of opinions, from stakeholder, including providers, and trying to solution how racs can still do their job and meet their obligations but decrease that burden. >> i think we are working on the -- it now. >> that's still under discussion? that's not a definite -- i've got a good actor there, as dr. gosa are had mentioned? >> it's one of many exclusions

we are looking at. we've heard a lot of input from the provider community and trying to take action where we can. >> we'll come back to that. >> thank you very much, mr. chairman. listening this morning, it gets frustrating up here. despite the fact that we all come from different communities and are sharing very clear examples as to why the approach that's being taken isn't work ing, we continue to get pushback and reiterating the same points without any clear idea of when things will improve. i represent the constituents in nevada. i'm talking about the beneficiaries here. and when someone who is medicare eligible can't see an ob/gyn in my community because there are no providers who will accept them, because of issues ranging from the reimbursement rate to

the delay in being paid for services rendered to other compliance issues, it makes me want to know what we can do and how in the short term to be able to move this forward. you know, medicare is a bedrock of our programs. we have providers who, about a third or more of their patients are medicare covered. as my colleague, miss gradilas risham explained, it also

typically includes medicaid or other paid sources as well. and so when you layer that burden on the provider, it's tough to provide services. that's what we're hearing. so after speaking to several stake holders in nevada, particularly hospitals and medical providers, all around the las vegas valley, and i also include some of the rural counties in nevada, which are woefully underserved by enough providers. the accountability of the recovery audit contractor

program seems questionable at best. i don't understand how you continue something not properly evaluated. while the programs have a notewor think mission of seeking out improper payments of medicare services, it seems there are potentially perverse incentives to these racs. in 2010, the program was expanded to all 50 states it made permanent. i don't know how you start something and don't expand it to all 50 states first of all. in 2013, over 192,000 claims were filed by these auditors to the appeals, contributing to a backlog of over 357,000 claims. the recovery audit contractor program, as i said, may have been well intentioned, but there have been unintended

but there have been consequences. so acting deputy inspector richie, in your testimony, you include a long list of policy recommendations for cms to address. you reported that 72% of denied hospital claims at the third level of adjudication are over turned, ultimately in favor of the hospitals. what recommendations have you offered cms and this committee to address the concerns that racs are, no pun intended, dramatically racking up the numbers of claims backlogged? >> i think, first, we offered recommendations both in the rac area and in the appeals area. i think it's important while so intertwined to consider those separate, in some ways, and a rac work, that was all the work that we have that we're talking

about was before this current backlog. we've seen things that we think are relevant in the rac work. we did see in 2010 and 2011, that they were helping as i mentioned in my testimony. we need to make appropriate payments and when inappropriate payments are made, they need to be recovered. only they did recover $1.3 billion in 2010 and '11. and 6% were appealed. clearly something needs to be done. i point to the alj work for the recommendations that i push to the most. for the system to really work and where the backlog is, we think the biggest recommendation we had is that medicare policies are not clear. and i think, you know, all fraud is certainly improper payments. but not all improper payments are fraud. most of the providers are not committing fraud, they simply don't understand a complex system and are trying to submit claims that are complicated. we saw in the alj work that 56% overturn 20% of the prior level overturned.

a lot was due to different interpretations of the policies. >> are there a set of recommendations dealing with the medicare policies? >> yeah. in our recommendations, because there are so many, it's mainly to clarify -- select the policies that need to be clarified. clarify those and educate the people on the policy to create less overpayment. in my written testimony, i talk about our home health work. we found with the recent face to face requirement if a physician is certifying you're eligible for home health they have to have a face-to-face encounter. we found 2 billion in improper payments in 2011 and '12. a third of the claims didn't meet the requirement. we don't think a third of the claims were fraudulent. it's because they are complex policies as people get more used to them. it will probably go down. to educate people on the policies, make them more clean we think is really a key to

keeping the appeals backlog lower. >> i know my time is up for this round. i'll come back to additional questions. >> recognize the chairman of the full committee, chairman issa. >> thank you, mr. chairman. thank you for holding this important hearing. the gentleman from nevada and i don't always agree. every once awhile, there's a nuance of agreement from this extreme to that extreme of the diaz. this is one where i think the entire committee is frustrated. and chairman langford's work on this, in addition to enc, really shows how bad things are. and let me just give you two questions, and then we'll go into comments. dr. agrawal, let me just ask you -- and for the ig, mr. richie, new york city -- new york state owes us $15 billion in overpayments. they flat billed more than the cms maximum for medicaid and we held hearings on that more than a year ago.

what have you done to get $15 billion back while, in fact, you send out hordes of people to harass doctors with a less than stellar success rate of success in accuracy in the audits? what have you done to get back from a state that knowingly billed far greater than the rate? and it's $15 billion. it's ten years worth of your recovery. any answers? >> so, that is an area we're looking at now. >> you're looking at it? $15 billion and you're looking at it? >> at the request of the committee, we have -- we are currently taking on an evaluation of new york state. we're waiting to get the findings and release the results, after which time i think we can have a conversation about how to proceed. >> the newspapers make it abundantly aware the numbers speak for itself. they are hard numbers of what was sent out versus the maximum allowed by law and you're looking at it more than a year later? >> sir, i think these evaluations do take time. they are rigorous.

they're designed to be rigorous. >> oh, they do? do you know how many doctors have had to stop their practices and answer nothing but questions because you take their money and then they try to get it back? isn't that correct? >> i whether or not characterize as stopping their practices. >> no. i'm telling you that doctors in some cases have to stop their practices because the audits for small practitioners are incredible detail. they don't get their money back until they prove their innocence through the process. let me go through this again. you have the right to stop payments in your state based on a good faith belief that they got over $15 billion. and then they can spend legions of time to argue why they should get to keep far more than they were supposed to receive. couldn't you? >> i would have to look into it. >> well, why don't you look into it, doctor? and while you're looking into it, pursuant to congressional action under the small businesses job act, you owe enc -- subsequently, we get a

copy of it. a second-year report on predictive modeling, don't you? >> yes. you've owed it since october? >> i believe the report has been due since earlier this year, but i take your point. >> no, you don't take my point. we did away with a bunch of reports through the congressional action. we ran it through the house. the senate may have acted on it. we ask for reports we don't always need. we didn't just ask for the report. we ordered the executive branch to deliver it. it is extremely important because the kinds of thing that the gentleman from nevada were talking about. auditors going out half you know what, being wrong and on appeal being dramatically overturned even to zero dollars, in some cases, after physicians and clinics go through a great process. much of that would go away if your predictive modeling went and looked for the fraud where it is most likely to occur.

mr. richie, are you concerned that chase manhattan can see your credit card perhaps being misused and calls you, but the organization that you're auditing has no such capability? >> that's definitely a concern. we do think that the fraud prevention system has taken steps and shows promise. i know, tie in to the other question with the rac work. one of the things that cms does when they look at the rac audits is they identify vulnerabilities if the cumulative issue is over $5 hun they need to address the 000. vulnerabilities and assess them. one of the rights was to fully do that. we found once they identifying recovery payments you need to set up the safe guards to prevent them from occurring in the future so you don't have the problem. >> has the ig looked into the excess payments requested by and given to the state of new york for the this committee earlier had as to whether or not any criminal charges could be

brought? >> i'm not aware of that. i don't believe we have looked at criminal charges. i dough -- i do know that we have -- >> but they knowingly overcharged more than the maximum and cross funded that payment to other services not even covered by cms, in many cases. the question is, is it worth taking a look to see whether or not the threat of criminal just might get new york to return $15 billion in excess payments? ten times what your audits that we're talking about here today in part are revealing? >> personally, yes. i think it's worth it. i'm not the enforcement person, but my office and audit, we've done a whole series of audits in new york that we've shared with the committee. i can go back to the office and talk to our investigators about this and our counsel and look into it. >> mr. chairman, i appreciate you giving me a little extra time.

i will say that i'm deeply concerned that reports that are required by congress that ultimately are necessary in order to improve the system are clearly done, but are being held back so they can be sort of looked at again and again. this is the politicking of releases. i would only suggest to the chairman that we have the authority to compel the work documents, if we need to, if that report doesn't come in a timely fashion from here on. i yield back. >> dr. agrawal, before i yield, this was a pending question from the chairman. when will that report come? we know it's months late. when? >> so, as you now, the small business jobs act requires us not only produce a report but have -- >> when? >> -- results certified by oig. we are in the process of working with the oig to achieve the cert certification. that is taking some time. i hope to release it as soon as we can. >> that doesn't answer a when, does it? >> i cannot give you a specific timeframe right now.

>> can you give me a week or a decade? >> it is less than a decade, sir. >> this is a report that all of us want. it matters to all of us. it deals with what we're dealing with, with providers, trying to shift us to where we all want to go. when? is it a month? is it two months? this is a simple question from the chairman. when? >> i cannot give you a specific date. however, i think what is important for the committee and for, you know, the american people and public transparency is that we not only release a report but release it with certification from the ig, so people can trust the numbers and base future decisions upon a certified report. the importance of that is clear, so we are working to achieve that. >> mr. chairman, only because the doctor did say public transparency, public transparency would be releasing all the work documents that show

the reason for delay, the political correspondents, the loop to the white house that deals with these reports. i rather doubt we'll get the transparency. >> mr. chairman, would you yield? >> i would yield. >> doctor, it's a pretty simple question. if you can't give us a precise date, is it three months, six months? and what is holding it up? >> as i mentioned, you know, again, we are working closely with the office of inspector general, as required in the law to try to achieve certification for this report. i think the importance of that is very clear. so people cannot only get a report but trust the numbers that are in the report. >> and, you know, we're not stupid up here. we understand when people are trying not to answer a question. so if you would, be kind enough to answer the question. is it three months away, six months away, and what is holding it up? >> i cannot give you a specific date. the reason i cannot is because it's a process that is being worked in collaboration between cms and the office of inspector general. >> you can give us a precise date.

you need to maybe ask someone else, but we expect to know. we have the right to know. i mean, if there's a problem holding it up, we have a right to know what's holding it up. >> it isn't an issue of holding up the report. >> do you have a draft report that is complete? is it just being agreed to by various parties that then makes it available to be released? >> again, i think our -- >> just answer that question. >> our -- >> answer the question. >> we are working with -- >> is the draft complete? >> there is a draft report that is -- that utilizes a methodology to arrive at numbers that the office of inspector general is reviewing or is in the process of reviewing. we hope to be able to release that report in the next month or two. i cannot be more specific. >> that's helpful. that's a lot better than earlier. >> miss duckworth.

>> thank you, mr. chairman. i would like to follow up a little bit on what the chairman of the full committee, mr. issa, was talking about, these rac audits. i agree that combatting medicare waste and fraud is a critical goal. in fact, there are studies that show as much as $50 billion are wasted each year due to waste, fraud, and abuse in medicare and medicaid. we need to go after that. but it's also become clear to me that the well-intentioned efforts of the cms are not working and are in bad need of reform. i want to talk specifically about how these audits, these rac audits affect the process throughout the industry and the patients they serve. i heard from providers from all over the country, many of whom are small businesses. how they're being targeted by overzealous and misdirected audit that threaten to put them out of business. the businesses cannot survive this. it undermines access to critical services to patients who

suffered from limb loss or impairment. often times these businesses are the only providers of prosthetics in their local area, which now means that the patients cannot get access and must go without the limbs they need for their lives. the volume of audits lead to a huge backlog in appeals for providers who feel they have been wrongly denied payment for legitimate services. i'm particularly concerned that cms has chosen to deal with this backlog by suspending for two years the ability of providers to appeal decisions at the administrative law judge law. with alj siding with providers in over half of all decisions and increasingly audits, it's simply unacceptable to deal with the problem by denying the providers due process. they're continuing the audits. you're taking these people's money by not paying them and saying now you have no right for appeal. you have to wait over two years. that's not the way businesses work and you're going to drive

these hard-working americans, small businesses, out of business. and you're going to leave all of their patients out there without the limbs and the equipment that they need in order to live their lives. at the public hearing on this issue, the chief administrative law judge griswold gave an explanation of how the office of appeals -- of their position but really offered no short-term remedies that would restore the right of a timely due process to providers. if you are going to suspend the hearing by two years, then suspend the rac audits for two years. give them their money back and collect it two years later. it seems blatantly unfair and unamerican to take these folks' money and not give them due process. does cms have any plans to restore fairness to the system for our providers?

>> so, just to clarify at the outset. the third level of appeals or the administrative law judge level is outside the cms. it's overseen by -- we have district oversight over is the first two level of appeal. >> okay. >> everybody is afforded, you know, any over determination whether by a mac, rac, or other contractor. providers are afforded the opportunity to use the appeal process as part of their oversight of us to make sure that the audits are being conducted properly and the right of terminations -- >> what is the backlog at the first two levels? how long are they waiting to get into the appeal process and getting it resolved? >> at the first two levels, the second of which is an independent level of appeal, or oversight, the oig published a report that shows there's no substantial backlog. the backlog issue arrives later. on average, we are within the time frames that are required of us. i would say, you know, in addition with respect to the prosthetics issue you brought up earlier. it's clearly an important area. if there are, you know, issues of access to care with respect to specific beneficiaries or companies, i'm happy to work with you on that. that's a priority for us. >> excellent.

i will have the orthotics and prosthetic industry come in and sit down and talk with you. what you're telling me is that the third level of appeals is holding everything up, and they've suspended for two years the right to due process. and even though this is being caused by the rac audits that cms is continuing to conduct, it's not your fault, it's someone else's fault, but you're still going to shove more people into the system who now have no access to this? it's kind of convenient, don't you think, that you're pushing people into the system with these aggressive rac audits, but on the other hand you're saying it's not our fault that they can't get through the third level. what are you doing to work with the administrative law judges to

fix the delay in the appeal process? >> sure. so we have taken a number of approaches to ensure that number one the audits are being conducted appropriately and whenever we can to help address appeals issues. we are actively working with omaha on their backlog and trying to arrive at solutions in conjunction with them. i think on the front end, where we have more direct oversight and authority, we've implemented strategies to ensure that the audits are being conducted correctly and with high accuracy. as one example in the rac program, we do have a validation contractor that looks behind the racs to make sure that the racs are following cms requirements and payment rules and guidelines and all of the racs have achieved well-above 90% accuracy rate of the findings. i think that goes a long way to ensuring the activities are, in fact, being monitored. we want to make sure the initial determination is accurate. >> i don't think it's accurate when 50% are overturned on appeal. i'm out of time, mr. chairman.

>> there's a statement that has been sent to us by the american prosthetic association. i ask unanimous consent to put it in the record. without objection. >> i want to followup on that. because you're acting like you have nothing to do with this backlog. and i think that is an unfair characterization. do you not agree? you have nothing to do with the backlog? >> i think, you know, clearly that providers would not a lot to appeal if we didn't enforce our rules and deny certain payments. >> let get -- let's look at this. the inspector general's report and they said that the overturn rate at the appellate level is anywhere between 50 -- depending how you read it. between 56 to 76% according to the oig, and so those don't get at the adjudication level without you doing something, isn't that correct? >> we, you know, clearly do a -- i think we have a number of steps. >> you have to review them first before they get here. >> they get overturned between

56 to 76% of the time according to the oig report in 2010? >> not only -- >> you disagree with that? >> no , sir. >> so you do have part of the reason why we have a backlog. because it's on the front end you're just denying claims and denying claims. i've talked to physicians and i've talked to hospitals. i've talked to health care providers. and, you know, they say the first fair hearing they get is at the administrative law side of things and that what happens is you guys are just denying them, and you're saying it's tough. so you have to pay it, and wait for your turn in the cue to get the hearing. do you think that's fair. >> i don't think that's a correct characterization. >> let me ask you another question.

it comes from the hhs.gov website. you changed that within the last 30 days. it's been changed. and what this says is that the average processing time for appeals are decided in 356 days. would you agree with that? for fiscal year 2014? >> again, sir, if you're talking about the third-level appeal or the alj level. i couldn't comment on their data. >> this is fiscal -- this is on your site. fiscal year 2014, the average appeals time is 356 days. would you agree with that? for fiscal year 2014? >> i think if that's what the data shows that's clearly what it shows. i think our -- >> how would we know that fiscal year 2014 hasn't even ended yet. it doesn't end until september 30th. how would you know this? >> i'm not sure what data you're looking at or how it reflects me. >> we can give you a copy of it. somebody in your office knows because you changed it within the 30 days because what you were saying is that they were not being assigned for 28 -- i'll give you 28 months and they

weren't being assigned. it's been changed. who changed it? >> i think the issues you're describing, hopefully it's accurate, they are really the third-level appeal or alj level issues. what i stated earlier we have oversight of the first two level of appeals. we are abiding by timelines required in the appeal. >> let tell me you, moms and dads back home could careless about the internal divisions. they see it as all part of cms. they see it as one of the same. they see it as the government. here we are for the budget requests we've got. this is the backlog is going to reach $1 million. at what point does it become a crisis? at what point? when does it become a crisis? when do you put companies out of business? you already are. when does it become a crisis you're willing to do something about?

this is your document. one million backlog by the end of this year. so is that a crisis? >> sir, if there are individual companies being put out of business by the audits, we have flexibility. >> but you don't. i've called on behalf of some of my constituents. that would be a great response but it's not true. because you know what, i've dealt with jonathan. i've called to make sure that kathleen sebelius knew about it. i've called the white house. and you know what? you say too bad. so what do i tell the moms and dads who are going to lose their job because they do not get a fair hearing? what do we tell them? >> we, sir, are able to do what we are authorized to do.

so whether it's an alternative payment arrangement or something else working with a provider. >> all right. you have five years for an alternative payment arrangement. i know, the stuff. i've been studying it for the last six months. five years. if the backlog is ten years, what do they do? they just pay it? because right now, at a million people, at the million appeals, your rate, the best rate we've had from adjudicators is $79,000 a year. even with your budget increase, that would still be a 10-year delay. that's a taking, in my book. would you wait for ten years for your salary? >> sir -- >> yes or no. >> we do whatever we are authorized to do in term of working with providers to make the system less burdensome. we can stretch out payments and change things in individual cays. we cannot overstep the authority that has been granted to us. >> but something changed. something changed. because you know what? the audits went through 1500 a

week to 15,000 a week. what did you change? because, i mean, it's in your documents. i would be glad to give it to you, too. they said it went from 1200 a week to 15,000 appeals a week. what did you change? >> again, i think it's important to level set on this. it's our obligation to audit. we have improper payments you've heard about from the other witnesses you've heard about from the rest of the committee. our obligation to go after those improper payments to reduce the rate and make recoveries where possible or where they should be made. that's an obligation created in law. to the amount of auditing we do. we audit far less than 1% of all claims we receive. all the overpayment determinations made by racks in the latest available public data account for less than one days' of claim. >> my time is expired. i would like one answer. the law says they need a decision in 90 days. is that law being violated and who makes the choice on what laws we enforce and what laws we ignore? the law says 90 days. >> i cannot comment on the processes that are outside of the jurisdiction of cms. >> this is in your jurisdiction. >> that's at -- >> no, this actually talks

qualifying independent contractors which is under yours. and the alj is 90 days after that. >> right. so as far as the second-level appeal at the qualified independent contractor level, there is recent reporting from the oig showing we are remaining on track as far as the expectations as to how long it goes through the appeal. >> jonathan bloom said you changed something in 2012. what did you change? >> sir, i was not part of that conversation. >> you know of any changes that have happened -- i'm out of time. i yield back. i apologize, mr. chairman. >> come back for the second round. i would like unanimous consent to have ranking member's opening statement to be entered into the record. you are recognized. >> thank you. i apologize for my late arrival. we had a memorial service at the arlington cemetery for servicewomen, i felt compel to

be there. i apologize for not being here for your opening statements. let me say at the outset, i've had local hospitals that have gotten embroiled in the rack situation. i have a hospital that is teetering on bankruptcy right now and the rack experience that is exacerbated it. but i also think it's really important for those of us who sit on committee to recognize we have an obligation beyond just beating up on those who come before us like this to recognize that if we want to fix the backlog, we've got to pay for it. there's a backlog because in 2007, rack claims amounted to $20,000. today that number is 192,000 a year. that's ten times what it was in 2007, and we have not added one single person to respond to those claims.

so if we want to deal with this backlog, if we want to erase it, we've got recognize that you cannot expect people to do ten times the work with the same number of work hours. now, let me start with mr. ritchie, if i could. you've had a pretty remarkable run in terms of the efforts by the health care fraud and abuse program which resulted in $4.3 billion in recoveries to the treasury in 2013. that represents 8 to 1 return. is that the highest level of recovery, to date, mr. ritchie. >> yes, that is. >> and how is that achieved? >> we partnered with our other partners in enforcement and the program to fight fraud, waste, and abuse through investigations, audit, through the evaluations we have done.

the recovery is reported in fiscal year '13 the record recoveries. >> i think in your testimony, you referenced that sequestration will result in a 20% reduction in the oversight capabilities, is that correct? >> unfortunately, yes. >> so what does that mean in terms of what you're going to do and what we're going see in terms of waste, fraud, and abuse being properly handled? >> for our office, it's, i mean, it's not good. it's less investigations, less audit, less evaluations. i mean, i'm not the budget expert, but i certainly live it every day. i work in our audit office.

i'm acting in charge of our evaluation office. at this point between 2012 and 2014, medicare and medicaid has been up 20%. during the same time our office had to reduce our focus on medicare and medicaid 20%. it's challenging given we have a $50 billion improper payment, a 10% error rate. it mean less auditors, investigators, evaluators on the ground handle this. i've been working there for 27 years. i can tell you personally we've never quite felt as challenged looking ahead to see what the growing programs and growing responsibility how we go about doing this. >> so should we roll out a red carpet for the fraudsters in this country? >> i would certainly hope not. in our office, we try to do a risk assessment to pick the best topics. we certainly make our budget request and for us personally, i mean, the best thing that could

happen is fully fund our budget request to get us back on target. it's decreased. we have gone down by 200 fte. 200 employees over that time. we've had to stop evaluations and audit. we had to stop following up on investigation leads. >> is it safe to say because of the reduction, there are investigations that haven't moved forward that probably would have resulted in savings to the taxpayers in this country? >> yeah, absolutely. i mean, investigations and audits both we have to make tough choices every day for what we start and can't start. i mean, it's been a very difficult time and sort of looking at this. i think you're make tough choices with things that look good. you do a risk assessment and feel there so much to look at. you only have so much resources and the resources are declining. we've had a higher increase. people have left through buyouts. we've been consistently reducing. >> so give us an example of kind of case you had to let drop by the wayside. i mean, do you drop case that are so big it would take so many resources so are the big fraudsters getting away with it

more than the little fraudsters? >> well, i'm not -- in our audit and evaluation offices i'm not there. i know, our investigation office told me they have closed 2200 investigative complaints since 2012. i think it's a mix. we try to do the best risk assessment we can and put resources on the biggest cases but certainly we can't afford to do those. i know, our strike force activity has been a big success and our strike force city we've had a reduction in resources. it's been across the board in every aspect of the ig enforcement. >> my time is expired. i'll follow up in the second round. >> i thank the chairman. and miss king i appreciate the gao report you put out. i want to go to the first

complete page. this is the second paragraph, the latter half of it. i'll read it. for example, cms hired contractors to determine whether providers and suppliers have valid license, meet certain medicare standards, and have at legitimate locations. cms is recently contracted for fingerprint based criminal history checks and providers and suppliers and identified as high risk. however cms has not implemented other screening actions authorized by affordable care act that could further strengthen provider enrollment. can you help enlighten me where you think they have not implemented other actions to strengthen the process. >> yes. i think there are a few things we point out. one, in relation to the bonds establishing of regulation regarding assurety bond for certain type of providers. one is not publishing the regulation that has to do with disclosure of past actions that have been taken against providers such as payment suspensions. >> so, doctor, why not do that? >> i think these are great ideas. when we have really appreciated

the agency has appreciated working with gao on for thing if anything figuring outs where our vulnerabilities and weaknesses are. there's nothing wrong with the recommendations. we continue have the conversations. we we have to prioritize -- >> we are trying to get rid of the waste, fraud,authorized by the law. >> it isn't a disagreement over the objectives. we have done a lot in the last couple of years to really, you know, beef up our approach. some of of the stuff like fingerprinting is coming online now. will are limitations we can get to. >> is there a prioritized list or summary that you can share with the committee? so we understand what you are prioritizing what you're doing and not doing? >> i think you're clearly seeing some of the priority occurring. >> where do i find that? is that something you can provide the committee? >> i don't know we have a list. i'm happy to have further conversations.

>> can you create a list? we're trying to get exposure and transparency which you say you're in favor of. what you're doing or not doing. the gao is saying you're not doing all you could do. you've got make choices. i want to understand what you have prioritized and what you're doing and not doing. is that fair? to put that on a piece of paper and share it with the congress? >> i think perhaps it would be useful to get your insight and, you know -- >> no. with gao. >> you want me to run your agency. i'll run it for you. but gao is making recommendations authorized by the law to do these things. i want to see what you're doing or not doing. i'm not looking for a 700-page report. i'm looking for a couple of page summary to understand what you're implementing and what you're not. you have to have some sort of document. i didn't expect to spend five minutes asking you a prioritized list of what you're working on. is it something you can or cannot provide to congress? >> sure. we'll work with your office to provide it.

>> when is a reasonable time to get that, doctor? you come up with a date. >> can you give me a few weeks to do it? >> sure. >> okay. how about a month. we'll get back to your office within the month. >> the end of june, how is that? >> perfect. >> thank you very much. one of the things i've been working on that i'm worried about is the providers. are we engaging and allowing people with serious delinquit tax debt to be engaged in the process. there's a big government-wide problem. we have contractors with serious deealing -- tax debt. i don't expect you to understand the question. it's something that i personally and the committee would benefit from understanding. what are the policies you have there. it should be a key indicator if you're not able to pay the federal taxes. why do we give you more and more business.

the president has been in support of this when he was senator obama. i think this is a very bipartisan thing. thing the committee dealt with a bill specific to that. if you can also provide me information about what you do with that and the answer may be we don't do anything with that. i would just like to know the an to that question. can we shoot for the end of june you give me that information is that fair? >> yeah, i think that's fair. but, i think, just to comment on that a little bit. we have all kinds of information we could collect from providers. i think the question often, you know, we have is what information can we collect that is actionable for us. so there are some clear bright lines in the program. if you didn't have the right license to practice medicine in the state in which you want to enroll, you don't get to enroll in that state. there are certain other type of disqualifiers like certain felony conviction. so i think con accept one could to look at providers. so i think conceptually it makes

a lot of sense to include as much risk assessment data and analysis as one could look at providers. i think we have to -- there's just sub set of those potential risks that push over the line and allows us to take action. if the provider, you know, the exclusion list or the -- >> i'm worried about the contractors you're engaging that help on this. that are supposed to help you engage with the people. those are some of the specifics that i would like to see as well. it's not just -- i'm not talking about the providers about contractors, it's the contracting that you're in order to be make these things, thank you very much, mr. chairman. i yield back. >> the second round for questioning. during this time, there's full interaction. you can jump in at any time. there's no clock run at this time period. for our witnesses, if you have specific things you want to get in the conversation feel free to initiate the topics to make sure you're clear. the goal is to make sure we bring all of the issues out, find the areas that need to be resolved, and work the timeline for resolution on those things. so you're free to be able to bring those issues up as well

and make sure that we have clarity on this. i want to reaffirm. let me first take a crack at a few things here. this panel is committed to how do we deal with fraud. there's $50 billion in unaccounted for money possibly overpayments in fraud. we affirm that we are pursuing that fraud. that is the taxpayer dollar. and it's essential. but for the solvency of the program long-term and for the taxpayer themselves. so, continue to do that. i think the frustration is the prepayments out of this, we all know that's the direction it should go, so we're not having to chase. that's why we want to know the report, we want to know what is happening at this point, and how do we get ahead of this in the days ahead and not having to go back to constantly good providers and say we're going to hold the providers. and for them to have a portion of their cases pulled and not paid for for an indefinite period of time as they go through the appeals process is untenable from them.

so, i want you to hear from me and from us. we're not opposed to going after fraud. we're opposed to the methods. there have been changes in the audit process as cms learned the way through this. we're proposing additional changes in this. to say what can we do to help expedite this process and make sure it is right and overturning the appeal, they get their money faster and they have fewer people engaged. so, let me run through a couple of these things again. we've gone through the revalidation process. is that complete for providers nationwide revalidated, the providers and fingerprinting, background, re-elron. is that complete at this point? what stage is that in? >> the revalidation process was initiated after the aca puts us on a five-year cycle. i believe the latest number is we have revalidated over 770,000 providers at this point. that puts us on track to being complete in time for the first cycle. >> so, two more years left of

that, is that what you're saying? >> i think that's about right, yes, if i remember correctly. >> then the prepayment pursuit of fraud, we have a report that's due to us. obviously, we've already discussed that. that's coming in the next couple months to give us the details and progress on that. then we move into the postpayment. do you make any comment on the prepayment side? >> well, i think just that clearly the affordable care act did provide us a lot of authorities to make changes on the prepayment front. such as, you know, payments suspension which we are able to leverage against the worst actors. i think the only point i would make, congressman, is to differentiate what we do when we're going after potential fraudsters, sort of criminals, the worst actors. from those providers, the vast majority, that are perhaps producing waste or producing inefficiency in medicare not quite following our rules. but have the intention to follow our rules. are trying to do their best. i ask to keep the framework in mind. i think it sort of determines for us what tools we utilize so

that they're not overly pejorative. i think payment suspension is great tool for bad ak toers but not for legitimate actors. it's essentially suspends all the payments they'd be getting. >> right. it's the hammer down in the area. even for the high-risk areas, where there's a moratorium, some of those areas may have a deficiency of a number of good companies that are actually providing. if you can continue that more people entering immediate care. medicare, there's a need for more providers. >> it is. i agree with you, sir. it's a notable piece of authority we implemented with a lot of care and over time. it took us years to go from having the authority in the aca to actually implementing it for the first time. i would say the areas we try to address, the geography and home

health services as well as ambulance services, are areas we knew there was a lot of market saturation. there was very little concern. we have been looking at it continuously about access to care issues. you know, home health and ambulance services and texas and south florida are areas of a lot of agreement with the office of inspector general, the department of justice within cms, within state medicaid agencies there's just a lot of market saturation. just three to five times the number of providers on average. so while access to care is clearly something we care about and looking at in real time to make sure the moratorium doesn't have negative impact. we're currently not seeing it in those areas. >> let me come back. i would like to get a timeline for everyone the length of time. you said they're on schedule. let's talk about appeal number one. someone has a problem. the rac caught it. the appeal number one is to who and how long does it take? >> sure.

i believe the first level of appeals providers have 120 days to file the appeal. there's a 60-day time limit. for the decision to be aachieved on the peel. >> they filed it right away. let's talk about your responsibility. they're responsibility is their responsibility. you have 60 days to respond, correct? >> correct. >> who is responding to that? they're appealing to who? >> i believe in almost all cases it's the mack administrative contractor that would handle the first level. >> so you have the rac folks making a decision, and then the mac folks that are making the response on the appeal, is that correct? >> correct. >> so there's 60 days to respond and you're saying that's on time. >> right. >> they disagree with that. they come back on the second level. who is that? 4 how long does it take? >> the qualified administrative contractor. the qac. they have 180 days to file the appeal. the provider does. we have 60 days to make a decision on the appeal. >> and you're saying that is on time as well in.

>> so, i have average times that are below the 60-day mark, correct. sort of 53 and 54 days for most appeals. >> do you have the overturned rate on both of those? >> it would depend on the specific audit. so is there a particular audit you're referring to? >> either one. the first or the second level. >> and rac audit, sir? >> rac audits, yes, sir. >> i would have to look. sorry. so, i think while i'm looking, let me just say, i think the overall overturn rate for the rac audits are between parts a and b are about 6% to 7%. that's in the latest data that is public. >> you're talking through the alj process? you're talking through the first -- through the first two? that's what we're trying to figure out. get a cumulative number. we have yet to see a cumulative number. >> no. i believe that the 6% and 7% numbers are all the way through

are ever overturned. >> okay. i'm trying to figure that out. the latest number on the alj is between 56 and 70 some odd percent in that level. >> correct. if i can perhaps explain it a bit. the rac, you know, make determinations. i think the latest public data is 1.6 million -- roughly 1.6 million claims were found to contain some overpayment. providers make a decision about whether or not to appeal those overpayment determinations. and basically at every level of appeal as you go through one, two, three, the number of claims going to the next level comes down. the overturned rate might vary between the levels. i'm not finding the level right away. that's helpful. thank you. at the first two levels we're seeing a 9% overturn rate for the racs in specific. >> both of them or each one? 9% at the first -- >> no at the first level of appeal. 9% for part a.

>> do you know part b? >> 3%. >> all right. for the second level of appeal? >> at the second level for part a is 14.9%. >> so 15% basically? and then part b? >> 0.5%. no, i'm sorry. i don't have it called out. i have the percentage of appeals that make it to the second level. i don't have the overturn rate for second level. we can get it to you. >> that's unknown. after that they have done 60 days in the first one, they've done 60 days in the second. they disagree with that as well. and now we're heading to the aljs. which as mr. meadows has

commented on, could take ten years to get to that spot, depending on the perspective you get. now, we've heard 28 months, but 28 months is pretty ambitious based on the number that are in the queue and typically handled. i know, you've said over and over again it's not your responsibility. we'll visit with them on this. it's the next level. and the fifth level is what if they disagree with that? >> there is another level they can go to which is, i think, federal district court level. >> okay. >> i'm sorry it's the departmental appeals. and then after that is federal district court. >> so, that's a fifth level? >> correct. >> okay. thank you. i wanted to get the context for everyone. jump in at any point. >> i guess my question is so let's look at part b, d and e. what is the overturn rate for that? which would include, you know,

some of the other stuff. let me add, i have a report here from your office here on april 2nd of 2014, that says that overturn rate is about 52%, is that correct? is this report correct from your office? would it be about 52% for dme overturn rate? >> i think it depends on what document and what level you're looking at. if you look at all dme claims. it's about 7.5% of all overpayment determinations. end up in an overturn -- >> we're talking about on the appellate report. this is office of medicare hearings and appeals. their report. so, those hearings and appeals, it says the oversturn rate is 5 %, is either fully favorable or partially favorable. 24.87 was unfavorable. and so with that, it would indicate that the overturn rate is much higher than what you would indicate. >> well -- >> on dme. >> there's a calculated overturn

rate at each level. what i communicated about the fist two levels gives you the overturn rate for those levels. >> i may not be real sophisticated. i'm trying to figure out how does your report say 52% here and what you testified said -- where is the difference? help me understand that. >> generally, as you go up at the various levels of appeal, providers make a decision at each level whether or not they appeal to the next level. what we see are some general trends. so, providers do tend to -- the number of claims appealed at each level does tend to drop. and the overpayment -- or the overturn rate can increase. so, at the third level of appeal, at the alj level, the overturn rate is -- i can totally agree with what's on your piece of paper. it probably does approach 50% for dme. but at lower level of appeals, given there's more claims that are appealed and fewer are decided in the provider's favor, the overturn rate is much lower. >> that makes sense. so, out of the 1 million in backlog that your budget request

talked about, how much of those would you anticipate, based on this rate, are going to be overturned? out of the 1 million backlogged appeals going to alj. >> i think that's an individual case-to-case determination. >> it is. but based on historical evidence, how many would be overturned? >> sir -- >> 520,000 of them. based on these numbers, wouldn't that not be correct. >> based on those numbers. >> let me ask you one other question. is the american hospital association, they have rac facts. per rac track, which this is all greek to me, 47% of hospital denials are appealed and, quote, almost 70% of these appeals are overturned. is that incorrect? >> i can't really speak to their data, sir. what we know, what we track the data, of course, very closely internally. our numbers would not agree with

that. if you look at the first level of appeal for part a. we see a 5% appeal rate that makes it to the first level. >> mr. ritchie, if i could interject. there's a problem here. why is it that if you've got enough money to go to the third appeal with the alj, if you can hold out that long, if you're not a single provider, if you're a big hospital, you can hold out. if you go to the alj, you've got a 60% to 70% chance of winning. why wouldn't everyone just go to that appeal process, if they can afford it? so, the question i have, why the discrepancy? what do you know about the alj system that allows for such huge swings in the determination? >> okay. what we looked at was prior to the backlog, but i think it's still relevant.

we looked at the alj and at the time 56% overturn rate. this was 2010 data. for the prior level to qualified independent contractor there was 20% overturn rate. the big differences we saw, again, i mentioned earlier the unclear medicare policies we think are a trigger to a lot of this. at the alj level we found they tend to interpret them less strictly than at the prior level at the qac level. because they're confusing and complex policies. they're open to interpretation. the other thing at the level it's more specialized. they have specific people looking at only part a, specific people looking only at part b. they have clinicians reviewing that. at the alj, they deal with everything that comes their way and relying on documentation and testimony of the treating physician to make their decisions. so the process is different. we've also seen the case files are different. it's more of an administrative thing. but the things they're maintaining and holding in the case files are different from

level to level and i think creates some of the inefficiency. for example, the alj level is still on paper. the qac has everything electronic. they have to print it out and send it to the alj. they have to get papers from contractors and sort them out. it is to clarify policy and to create one system that's electronic. >> if i understand you correctly, at the qac level, they're very specialized, they know precisely what they're looking for and they make the determination because they're trained to look for certain things, i guess. i guess that's part of what you're saying? >> correct. we didn't assess and look at which level is better. they are very different. but at the qac level they have clinicians looking at it and specific of a complaint or appeal comes in specific to part b, it comes into part a, it goes there. where as alj, they've got everything -- >> aljs aren't clinicians. they are using discretion in terms of interpreting the law.

>> in terms of interpreting the law, and then they're relying more on the treating physician's testimony and evidence, whereas at the qac level they're relying more on their own clinicians to interpret the documentation. >> oh, i'm sorry. go ahead. >> if congresswoman speier will yield. it speaks to larger issues. i want to get back at, what are the real overturn rates? are we targeting correctly? what can we do to improve the system so we're not harming good providers, which means we are harming just beneficiaries, going after fraudulent and wasteful behavior. medicare is an incredibly complex system. the reality is, that if we don't start dealing up front with the medicare complexities, we can chase this all day long and go from one extreme to the other, and we're going to find significant flaws in our ability to hold providers accountable and to support providers to do a better job.

and what we haven't done in this conversation, i'm as concerned as anyone else about getting it wrong and overpayments. i'm also concerned your part a providers, large providers, and part b providers, even though we might have hot spots with the dme providers, that they can't afford to go through this process. so, in that regard your data is skewed for one group. and i'm not trying to vilify one group over another. but hospitals, large hospitals and large hospital groups can afford to wait a decade, potentially. smaller hospitals, as congresswoman speier identified, my colleague from california, cannot. i want to get back to a couple of things. one, then yield back. can you give us some recommendations -- you talked about the predictive modeling. you say we are identifying prescription practices that are clearly problematic. is there a way to be targeting

those areas? and is there a way to start targeting areas where we've got real issues with access. because cms has a responsibility to assure access. we're only doing one side of this here. we're eliminating, potentially, access. no response about that. >> so, recommendation -- i'm sorry, could you clarify, recommendations for what? >> a couple. the first is, you identified in your testimony that there are areas that you've identified that we could start looking at much more directly and aren't. so we could do predictive modeling in terms of where folks commonly make mistakes and where we've got potential fraud. and, two, you identified in that discussion, i don't know that it was tied to the predictive modeling, per se, but you've identified prescription practices that are clearly problemat problematic. you said, i think you've got folks who are not prescribers, as an example, prescribing medications for beneficiaries.

why aren't we focused more in those areas? and then i wanted either dr. agrawal or someone else to talk to me about what we're doing if you've got hot spots for fraud, what are you doing to shore up mistakes, so that we don't lose those providers by providing better education and support to those providers, and creating in low access areas frontier and rural states, what are you doing to assure you don't lose providers. >> thanks for clarifying. we make those types of recommendations all of the time. we have a series of reports that we call questionable billing reports, several of which i referred to in the testimony. finding questionable prescribers, questionable pharmacies and questionable home health agencies. in all of those cases we take the ones that we've identified that are extreme outliars based on the statistical test and give it to our investigations office to see if they want to further pursue, because these look severe. after that we send them to cms and cms will share with their contractors to take appropriate action, and we always recommend

that they take the kind of questionable criteria that we have and implement -- i know the fraud prevention system is starting to build some of that in. i think specific to the example that's mentioned in the testimony, and you mentioned on the prescribers, we saw, we have $5 million in a year prescribed by people without authority to prescribe, massage therapists, and things. just yesterday, i have to look at this because it was late last night that i got it, but cms actually issued or published a final rule that requires prescribers of part "d" drugs to enroll in the medicare fee for service program starting next june. june 1st of 2015. this is going to allow cms the plans and medicare program integrity contractors to verify that they actually have the authority to prescribe. because now they aren't -- a massage therapist isn't billing medicare, but they could write the prescription, for drugs that we found that were pretty severe. so that problem will be fixed based on this rule. so we are working with cms to get some of the recommendations implemented. but i think it's a combination

of doing things like that, and implementing edits on a prepay basis to try to stop future improper payments. >> i think what we're interested in -- i'm taking too long -- but is to get the information to the committee so we know when so that we can weigh in on how you're balancing these issues. and if the chairman doesn't mind, can we get something on the access? what are you doing to ensure that small providers aren't discriminated even further in this process because of the size of the provider and the capacity of the provider? and have you thought about treating them differently? like we have tiered regulatory environments. what is your thought about making sure access is protected? >> yeah. again, i appreciate the question. that is an extremely important area for us. so as far as tiering providers, we do currently tier providers by size. we actually have medical record

request limits, specifically for the rac contractors based on the size of the provider. i had also mentioned earlier a sort of future solution where we would ratchet down the number of reviews that a particular provider would face if the reviews are generally in their favor. in other words, they're basically following the rules. we're putting that solution into our rac procurement process right now so it will be part of the racs going forward. i think -- you know, in addition to that, we do take -- if there are overpayment determinationings, we have a process for the provider to work with us and change the payment rate in order to still meet our requirements and still meet the requirements of the law, but to be able to afford them a longer opportunity so we don't put providers out of business unnecessarily. i would also say, just on the front end, we are undertaking a lot of efforts to better educate providers about our specific payment policies. you know, i think the dme face

to face -- home health agency face-to-face requirement is a good example of that. where the improper payment rate is very high because of this new requirement. providers need to be brought up to speed. we are trying to do both specific audits that are look at that issue in order to educate both the home health agencies and the related prescribing providers. we also have just more general educational material that providers can take advantage of. we do try to be very transparent on the front end about what audits we're conducting. so once a new audit area is approved by cms, that we put that information on a website that providers can look at, both big and small tox shore up their own self-audits, make sure their compliance is working and prepare for audits in those areas. we hope all of this makes the process more open -- >> if it doesn't, what do you do to assure ak snes. >> right. so, you know, i think part of it is we have an open door policy for providers.

we do want to hear about the shortcomings of these programs if there is an access issue or -- >> and you don't think the providers by and large are going to be concerned about that open door policy particularly in the context of audits and your efforts for fraud, waste and abuse? because when i was the secretary of health and secretary of aging, i appreciate that mind-set. we're here to help you. and, by golly, no one believed that. and so i didn't really find that to be an environment that was very productive, particularly when somebody came to us and in fact they were fraudulent and we did our job. that certainly precluded that kind of a relationship. can you please collect data for us, if you don't already, and provide it to the committee so that i can see, we can see what the percentage of small providers that are engaged in any level of these appeals versus the large providers? >> yeah. i think we can do that and i think it would helpful to work out a definition for small provider that we could focus on. >> the last thing i would say, i'm trying the patience of this

committee, and i'm sure our witnesses, but i would -- i would -- again, this committee wants you to ferret out fraud and to stop those back actors and actually move those to criminal prosecutions and to prevent those folks from ever being able to engage in any of our health care systems or any government contracting ever again. we're that serious about fraud. and we also want waste addressed. but i'm getting very concerned really about that access issue and this is completely imbalanced. i would like for you to consider and mitigate that by telling us what the risks are about changing the withholding of payments for the third level of appeal taking into consideration a new definition potentially or a refined definition for small providers. and to entertain that and maybe come back to us in writing about what that would look like. thank you, mr. chairman. >> dr. agrawal, the passion with

which you've heard me today is not meant to be directed at you. it's a passion based on a number of people back in my district that potentially will lose their jobs. and i for one, nor you, do i believe you want them to lose their jobs because we have a system that is broken. when the chairman called this hearing, it was really a hearing about making sure that those who steal from seniors -- because that's really what this is about. is fraud. those who steal from seniors get caught. but in the process there are a lot of potentially innocent people that are getting caught up in that dragnet that we had to find a better system to do that. i would ask you to submit to this committee, if you would, two legislative changes. if you're saying that your hands are tied, what are the legislative changes that you would support and recommend for this committee to, perhaps, have the chairman introduced where we can fix it to make sure that we do go after waste, fraud and

abuse, but those that are innocent don't have to wait forever to get that innocent verdict. and in the meantime, potentially go out of business. and i yield back to the chairman and thank his patience and his foresight in having this particular hearing. >> let me ask a couple of questions to follow up on that. it goes back to what mr. meadows was saying as well. good actors we want to keep. our seniors need to know, in my neighborhood, in my community, in my town, in my county, there's a good actor that's there. we have all talked to folks -- i'm sure you're aware as well, on several areas. last weekend i had a gentleman that came to talk to me that wanted to tell me about the last year of his life because he was a durable medical equipment provider. was. he's now been put out of business. he was a good guy. he was willing to meet the price that was out there made publicly

available in the competitive bidding process but was not allowed to actually join into that, because as this group knows well, when the competitive bid was put out, if you didn't get the bid, you're out. and not just out. you can't join in even at the new low price. you're just out of business. he's one of those that came to me and said, i just want to tell you about the last year of my life when my family business went out of business and closed down a company and laid off employees, and here's what that looked like. i have individual providers that come to me and say, i had a group of files grabbed not being paid for that are going through the appeals process and i'm fighting my way through that. and then as i'm fighting my way through that, i had another group of files that was grabbed, and now i'm fighting through those. and i'm on a different time period. and i'm not making payroll. i understand the comment of saying it's 1% or 2% of files,

but if they start getting a set grabbed and then 60, 90 days later, another set grabbed and they're still unresolved from the previous one, they're not going to make payroll for the smaller companies. these are very real issues. we want medicare providers to be there. we want our seniors to have access. we want individual health care folks to know if you take care of seniors, the bills will be paid. that certainty is disappearing at this point and that's a bad formula for where we are five years from now. six years from now. that's why the urgency of this is extremely important that we get ahead of fraud rather than constantly chasing it. because when we're chasing it, we're also hurting companies that are the good actors, that are trying to do it right. we are all for shutting down bad actors, aggressively going after that. knowing the good actors made a mistake, an error but now they're having a difficult time making payroll on it. we're losing the good guys in

this a that's going to hurt us long term. let me shift a little bit. with the rac audits. dr. agrawal, you and i talk briefly earlier about this. the incentive for them to -- if there's a question that this is going to get lost in an appeal for them to not pull that, for them to actually work what that. i will tell you, you probably heard the term before, many of the hospitals and providers call the rac audit folks bount hunters. they come in, land, go through stuff until they find something because they get paid based on what they find. the incentive is not to be able to sit down and say you made a mistake on this, let me show you how to do this different. the incentive is i got you and i'm going to get paid. that's a bad relationship. that's forming between our government and the people that we're supposed to serve. now we've got to set up an environment where the incentive

is for them not to work with someone to find and work this out and how to learn on it, but to punitively pull a file. that's a whole different set of relationships there. so the question is how do we get back to the incentive with the rac folks to be helpful rather than punitive, but we still go after fraud? ms. king, do you have an idea on that? >> sir, if i might, the other types of contractors that do postpayment reviews, the mac, the zert, and the z-pics are not paid on the incentive basis. they're paid on the basis of cost under contract. the payments for the racs were actually established by law. and how they were -- >> correct. >> so that -- if you're concerned about the incentives, it's something to consider. >> i think that's a very helpful point. i would also say, you know, we do provide -- so i think -- let me make two points on this. one is we provide oversight to the racs. so the characterization that they might be on a fishing expedition or making judgments just to receive the incentive

payment is, i think, not accurate because we do do that validation work hyped them to make sure that their accuracy rate is very high. that accuracy rate -- >> is there an incentive to be helpful while they're there, to teach someone how to do it better or is the incentive to be able to pull it? >> i think there's two kinds of incentives that work in the favor of providers. one is the racs are equally incentivized to find underpayments to providers. they get the same contingency fee if they return money to a provider that they deserve, as they would when they make an overpayment determination. that's just one. the second thing is, we have made it a priority in the program, both for racs and macs and other auditors, to use education as a tool. so when deficiencies are identified, they can communicate those to providers and hopefully providers can, you know, rectify that deficiency going forward. >> are they paid for the education? >> well, the racs are not specifically paid for that. but the mac contractors do work very closely with providers in all of their regions to, you

know, teach them about medicare policy and payment requirements. we also utilize the results of both mac and rac audits to alter our programs, you know, be more specific on policy issues where necessary. make changes to processes. so that is a priority for the agency. we do try to use the outcomes of these audits to alter our interactions with providers. >> what is the incentive for them to educate? >> i think what racs have been able to do is take areas that we know have high improper payments in them, again, differentiating improper payments from fraud. >> right. >> racs are not necessarily designed to go after fraud. those are other contractors and other areas of work. what we've asked them to do is focus on areas of high improper payments and make recoveries where appropriate. along the way they do identify educational needs, or, you know, clarity deficiencies that we can address either through other contractors or directly.

>> mr. norton. >> thank you, very much. mr. chairman, thank you for this hearing. when -- perhaps because medicare is necessarily costly program, i say necessarily, we do the best we can to provide maximum care for the elderly when they are ill. there is particularly concern when there are reports and they are always quite sensational, reports of fraud or particular abuses in the program. and i note that the affordable health care act gave the cms several new -- or at least several new -- or at least expanded authorities to deal with fraud. i would be very interested in hearing about how you deal with

those at higher risk and how you deal with them when they apply -- when it applies to providers and suppliers who are newly enrolling and those who want to revalidate their participation in the program. >> sure. thank you for the question. so as a result of the affordable care act we've been required to implement a whole new approach to provider enrollment and screening that takes into account the risk level of that category of provider. higher risk categories of provider like newly enrolling dme or home health agencies are subject to greater scrutiny. that scrutiny can include -- or everybody certainly gets certain data, analytical work to make sure that, you know, providers of all types have the right licensure, have the ability to practice in their provider

category. higher levels of scrutiny also include site visits, criminal background checks, fingerprinting most recently. as a result of those activities -- >> have you done fingerprinting before? >> fingerprinting we are just bringing online. we procured that contractor last month and we are -- >> all providers or for the high risk? >> the highest risk providers will be subject to the fingerprinting requirement. as a result of those activities, we have revoked -- and through the revalidation process, we have revoked over 17,000 providers since the aca, and deactivated an additional 260,000. >> for example, for what kinds of abuses or fraud -- or is it fraud? >> all manner of activities, really wherever they do not meet our requirements. so lack of appropriate licensure would result in a revocation. the presence of certain felony convictions on criminal background checks would result in revocation. failure to disclose information required on the medicare application, or to report that accurately.

>> would these providers be barred period, permanently barred? >> we -- the actions that we take, of course, are governed by the authorities that we have. revocation allows us to remove these providers for, i think, i believe up to a maximum of three years based on the infringement. beyond that law enforcement has exclusion authority that lasts longer and is more sort of widespread in its impact. we do work with law enforcement on utilizing -- >> have you had occasion to refer a number of these to the u.s. attorney or other law enforcement? >> yes. we actively work with law enforcement on referrals. but also even prior to the referral. so i think we've given law enforcement an unprecedented access to cms data, realtime access to our systems the same that we utilize in our analytical work. as cases develop we're in regular connection with law enforcement about cases they may be interested in and ultimately do make formal referrals that

they can choose to accept. we work with them on the entire investigational process as they deem necessary to provide them additional data or any assistance that we can. >> i'm interested in this temporary moratorium. this is apparently a new authority under the aca for a new medicare providers and suppliers. what would evoke that and how does it work? >> sure. so since the aca we have implemented essentially two phases of the moratoria essentially against home health agencies or newly enrolling home health agencies and newly enrolling ambulance suppliers am a few different geographies across the country. before implementing that moratorium, this was a big step, because it is a, i think a notably important piece of authority that we were granted. before implementing it we worked very closely with law enforcement to make sure we were looking at the right looking at the right geographies and the right provider types. we work with state medicaid agencies and across the agency, across cms to ensure that we were going after the right areas and also not having or

potentially would have a deleterious effect on access to care. what we ultimately chose were geography types and provider types were markets that were saturated by these provider types. roughly 3% to 5% higher market saturation in home health agencies and ambulance suppliers than the average, you know, geography across the country. so far the moratoria have been in place for -- first phase was put in in july of last year. a second phase in january. we continue to monitor both cost issues as well as access to care, and we have not noted any access issues thus far. i would say the moratorium has been a useful tool. i believe law enforcement finds it a useful tool as essentially a pause in the program so no new providers enter a geography and bad actors can meanwhile be rooted out. just as examples of work that we've done, we've revoked over 100 home health agencies in miami alone, more than half of those during the moratorium

period and over 170 revocations of ambulance suppliers in texas. >> how do you keep beneficiaries from being affected, particularly with that large number in one location? >> right. that is absolutely a priority of ours. we started by choosing areas that were very saturated to begin with. these are not areas where access to home health services or ambulance services was threatened in any way. even med pac had agreed that both of these provider types, as well as the geographies were appropriate to go after. since implementing them we've stayed in constant contact with the specialty societies that oversee these areas. we've worked with state medicaid agencies with cms regional offices that directly receive complaints from either providers or beneficiaries to monitor for access to care issues. and as i stated earlier, we have not identified those issues so far.

>> finally, ms. king, have you had occasions since these new authorities to look at their effectiveness and their implementation? >> we have not. we evaluated the enrollment process just as these new authorities were going online but we have not been back to look at yet. but we concur that front end strategies on the enrollment side that making sure that the right providers are enrolled and the ones that are at risk for being fraudulent are prevented from being enrollment is an effective strategy. >> thank you very much. >> let me run through some quick questions and we're nearing the end. the end is near. i want to confirm again the percent of patient files pulled for a rac audit. you've used the 1% number several times. is that accurate around 1%? or do you say 1% or less? >> the 1% is not just the rac audits, it's all the post-payment audits. >> that's every category, durable medical equipment,

physical therapy, hospitals, labs, whatever it may be? in every category it's 1% or less? >> yes. well, the aggregate number is less than 1%. >> that's what i'm asking. for each category. are there categories that are higher that are considered more high risk so there are more that are pulled in that category? >> i don't know the answer to that. >> do you know, dr. agrawal? >> i can't answer the claim question. but in terms of prioritization we clearly do focus on high improper payment rate areas. i think that's a requirement of the contractor itself of the program that we focus on areas where the improper payment rate is much higher. than in other areas. so you would expect to see greater portion of audits in say, for example, durable medical equipment or home health agencies. because those are where a lot of the improper payments -- >> that's what i'm trying to figure out. is that category higher than 1%

of what's pulled? >> you know, we can -- we can look into this, but i believe that most of the rac audits are focused on the -- on the part "a" side. even though that the rate of -- the rate of improper payments is higher in durable medical equipment and home health providers. but the actual dollar amounts of the improper payments are higher -- >> sure. it's a larger bill as well. part "a" is going to be larger than what's going to be in part "b." and most of the smaller providers. i would understand that. but it may be large to them. so if you've got -- again go back to the physical therapy clinic, privately owned, fewer number of patients there, it may be a very big deal to them to have 2% of their files pulled. than it would be to a hospital. as far as just general overhead. dr. agrawal you mentioned as well about good actors in this. the possibility and i heard a lot of, you know, variances put in that, maybes possible, we're looking at statements in it for good actors that are out there. once they gone through, they proved to do well, they didn't have a lot of inaccuracies.

how do we slow down the process so they're not coming just as fast to them? again coming to, again, an entity that's set up to do compliance now more than it is to take care of people. where are we on that? give me the process. >> sure. one solution that's been proposed is to lower the volume of medical record requests that could go to a provider that in previous requests has had a low denial or overpayment determination rate. that i think is a good idea. we've heard it from a number of sources and we're implementing that approach in our next round of rac contracts, pro-sizely so that providers that have been audited, that have done well in the audits and shown that they're following the rules will face fewer audits and lower volumes going forward. >> is that less frequency of audits or they're grabbing a smaller number of files when they come? they're coming just as often, they're maybe just doing half of one percent, rather than 1% or they're coming maybe once every two years so they're in their building less often? >> i'd have to confirm. i know that the volume per audit

will be decreased. but i have to confirm if the frequency would also -- >> i would recommend to you both are important especially to part "b" folks. they're trying to run a business and if they prove to be good actors in this, the frequency matters to them, when they have to stop -- obviously the volume that is being withheld from them, not being paid to them, makes a big difference for them making payroll. but it's also extremely important, they're able to focus on their business and not every 60 days, 90 days, have to stop and do another one of these if they've already proven they're doing well, they're following the rules. so i would recommend to you both they're examine on both frequency and number of files they're pulling. has there been a study to look at the compliance cost for the providers? mr. ritchie mentioned before around $700 million has been recovered this year. is that correct? >> yes. >> do we know what the compliance cost is? has anyone seen a figure to that. >> not to my knowledge.

>> most of the regulations that are out there when they're promulgated there's an estimated compliance cost for the promulgation of the rule that has to go through based on the requirements. the question is do we now know with more certainty what the actual compliance cost is? where would i get that? >> i'm not aware that such a study has been done. we have not done one. >> okay. >> we haven't either. i'm not aware of it. >> i can go back and look at the beginning, when it was originally promulgated there had to have been an initial estimate that was put out at that time as well. i'll go back and pull that. we'll work through that on our side. we don't know when another one has been done since then. and then last set of questions here on this. the pausing the racs. mr. chapner and i have had a conversation that when there's an intermediary change, tiply when it changes to a new one the old intermediary starts losing employees quickly and they're trying to maintain the rac audits with fewer staff and

everyone's leaving because that company is shutting down or shifting to a different spot. the other company is still trying to fire up and get ready but it's very slow. but the speed of racs can be the same across that. though the old intermediary can't keep up and the new intermediary can't keep up and you've got a drag in response time. my conversation is can we reduce the number of racs during that transition time when the intermediary changes. if the authority exists to do that, where is the authority to also slow down the process to allow us to catch up on this backlog somewhat? to say we're still going to continue to do this but we've got to slow this down because if we're approaching a million files sitting out there with more still coming, they will never catch up. it doesn't matter how much we fund it. we're not going to catch up. and that's a lot of money to be held from individuals. what is the conversation out there related to that? >> we do realize that as we procure the next round of rac contractors that there is a sort of transition issue.

what we've done is pause the rac program during this transition. what we don't want to happen is for one contractor to initiate an audit, and for a second contractor to then complete that audit. so we are working -- >> happens all the time. >> we are working to avoid it this time. so the last round of audits were initiated or permitted to be initiated at the beginning of february. those audits must be completed in a timely manner. so that -- and then the racs, the current batch of racs can find down and then the new batch of racs can find up. during the pause we're using it to -- taking advantage of it to alter the rac program based on input that we've gotten from providers and other stakeholders to make it more transparent to providers, to provide more education, and to make sure that it's focused on all areas of improper payment. >> and when will that be public? >> the procurement process is going on right now. we're following sort of stand federal procurement requirements. there are statements of work that in order to actually get proposals, that either have hit or will soon hit, you know,

public transparency and contractors will be able to respond to. >> okay. any final comments? bill, i appreciate you. >> no, sir. >> i appreciate you being here and for the conversation. your work is extremely important both in transparency and helping us deal with improper payments and fraud. i think you've heard from this committee pretty clearly we need the balance. we need providers. right now with what's happening in health care across the country, we're losing providers. and anything that discourages a provider from continuing to stay open makes the problem worse. we have more seniors every day joining into medicare and we have a problem with providers staying in based on reimbursements and based on just sheer compliance and the frustration of that. this is reaching a really bad spot and we've got the make sure we're working with providers to keep the good actors and then weed out the bad actors and educate those that just made a

mistake rather than push them out of business. with that we're adjourned. c-span's 2015 student cam competition is under way. this nationwide composition for middle and high school students will award 150 prizes totaling $150,000. create a five to seven-minute documentary on the topic, the three branches and you. videos need to include c-span program, show varying points of view and must be submitted by january 20th, 2015. go to studentcam.org for more information. grab a camera and get started today. in the kentucky senate race, republican mitch mcconnell, who

is the senate minority leader, is in a tight race for re-election against democratic alison lundergan grimes. the candidates debated on monday. one of the topics was the minimum wage. >> the minimum wage increase that she advocates is going to cost us a lot of jobs for young people. a much better way to target the low income people you're talking about is the earned income tax credit. the way to deal with that under -- underemployment problem, those employed, without killing any jobs at all, is the earned income tax credit, which is already a part of the tax law and ought to be grown and expanded. >> let me stop here, bill. that's amazing to hear the senator say the earned income tax credit is something he thinks should be grown because he's supported budgets that actually slashed that, as well as the child care tax credit.

two vital tax credits that help our veterans. 28,000 kentuckians, 140,000 military families. 300,000 children. >> did you -- >> in pofrt. his record is against the earned income tax. >> i don't have any idea what she's stalking about. i've been a long-time supporter of ietc and child care credit. >> he supported budgetings, bill, that slashed this funding. sthees should be made -- >> with all due respect. in a large budget vote, there are probably things in there that you can pluck out that any one of us might not have preferred. when you put together a secretary, secretary grimes has not had this experience yet, but when you put together a whole budget, you're not going to approve of absolutely everything in there. what the budget is designed to do is put an overall cap on what we're going to spend. and you can't serve? a legislative body and not cast a vote for something you're not

crazy about because there are other things in the measure you like. >> you can watch the entire kentucky senate debate at c-span.org. in kansas incumbent senator pat roberts is facing independent challenger greg orman in a race. we're covering that live from wichi wichita, kansas, at 8 p.m. on c-span. now a discussion on the annual international aids conference held in melbourne, australia last sumpl. panelists review the latest scientific developments and future funding for aids research. speakers also comment on malaysian airliner shot down over ukraine. some passengers aboard the plane were traveling to the conference. the kaiser family foundation and center for strategic and international studies co-hosted this 90-minute event. >> good afternoon, everyone. welcome to the kaiser family

foundation and to our joint event for center for strategic and international studies to look at outcome of aids 2014, which is the 20th international aids conference which wrapped up in melbourne a couple weeks ago. we have three distinguished guests with us today who i will introduce in a moment. thank you. i first want to acknowledge and thank csis and steve morrison specifically for this ongoing collaboration. we have come together, our organizations, for five conferences, the major conferences afterwards to do this kind of gathering with d.c. community to really take stock of the conference and try to understand what we learned from it, what it means for going forward. so thank you so much for doing this. and second, given the large audience that signed up for this and that is actually here, i'm just curious how many people in this room went to the conference

this year? raise your hand. so most of you did not. understandably it was far away. so this is good. this is why we were trying to do this, so we could bring you together. but on a more serious note, i just want to say a few words about the tragedy that befell all of us as we set out to get to the conference and that's the crash of malaysian airlines mh17 on july 17th, literally on the day that most of us were traveling to melbourne. i can't speak to how it felt here on this side of the world but i can say that it can't be separated from the experience and the meaning of the conference itself. we are, all of us, collectively lost six incredible people who devoted their lives to fighting aids. i want to name them all. they were, joep lange, the co-director of the hiv netherlands research collaborator, science director at the amsterdam institute and former president of the international aids society.

jacqueline van tongeren, pim de kuijer, who is at aids fund now, martine de schutter, lucy van mens, who was at the female health company, and glenn thomgs of the world health organization. beginning of the conference which was somber and serious and full of a lot of shock and some pain. it also reminded all of us something really important about our community and the response to hiv, and that is the community. it's a community of scientists, of activists, advocates, of patients, politicians, many times embodied in the same person. so just to remember these individuals, i'd like to quote a friend of mine who worked very closely with joep and jacqueline, dr. kate hankins as a reminder of who they were and what this means for our community. and also, you know, frankly to

recognize the act of violence that occurred that took them. these are kate's words. they were a tribute she just gave a few days ago. about joep and jacqueline in particular. as she said, it is incomprehensible that people who worked so hard to save the lives of others should be shot down and be collateral damage in someone else's war. each of us needs to reflect on how to celebrate their memories by taking forward their visions. this world is a better place for them having walked among us. let this be said of each of us, too. so with that i want to just say a few more words about the conference itself which was anticipated to be smaller than prior conferences because of where it was, and it was in terms of the attendance, and not expected to necessarily have scientific breakthroughs. it didn't. but nevertheless, it had an incredible richness that i am not sure was felt here and an incredible depth in what was presented and the coming together of lots of communities. in terms of highlighting what

many of us feel is an emerging global consensus on where we need to go from here that's not always been present. on emphasizing the importance of focusing on key populations, those who are marginalized, men who have sex with men, transgender individuals, drug users, and addressing and confronting stig thma and discrimination in all their forms around the world. the emphasis on the need to scale up treatment and what we know how about treatment and how effective it is, but also the power of prevention again, and some exciting new information about prep, which i'm sure we'll talk about, among other things. so for now i'd leave it at that. i'd like to ask our three panelists to come up. i'm very pleased we're joined by ambassador deborah birx, ambassador at large and coordinator of the u.s. global aids program. dr. chris beyrer, steward of the national aids conference.

and dr. steven stephen morrison, senior vice president and director of global health policy center at cisi. so please come and join me. [ applause ] that's my most important job today. okay. so as with usual in our events, i'll ask a few questions of our panelists and we'll pretty quickly get to your questions, and i hope this is a dialogue, especially for those who weren't there who want to get a sense of how things really played out because we know that the media itself didn't cover the conference extensively. that's been a trend we've seen for a long time, and so bringing that information here is really a critical task that we want to help with. so my first question is going to be the same question for each of you but i'll start with ambassador birx is just to get a sense of your main impression and takeaways from this year's conference.

what are some of the big themes and the ones you hope to continue as we carry forward this work. >> great. thank you. and thank you for having me here again today. and thank you for all of your information that you put on the kaiser website about every applicant over the last four days, they all reference the site. and how much they utilize the site. aids 2014, i think when you start out with that level of heart break, it really required all of us to be very intro speccive the entire week because many of us came from that time when there were so many unexpected deaths among our friends for an unknown reason back in the early '80s. it was tough to have that reflection at beginning. but every time i was in a planner or every time i heard something, i was able to -- you are able to think about the history of hiv/aids and where we are. to me, it was historic content of our 30 years together and where we have been and where we have been together.

so what started out as heart break i think came forward as very much as hope. when u.n. aids released its global report -- hopefully, you have seen it. it's a return to fundamental data reporting from u.n. aids with clear a naturnalysis we ca understand the first time we look at the graphic without a lot of sub text. you only have to look at the pictures and you will -- thwhici appreciate. you will get a sense of where we are around the globe. then i think to me the last thing was renewed commitment and the sharing of that shared experience of the beginning of the week really -- when things happened and when advocates and activists spoke, there was a true true resonating theme through awful us. wh when they were talking about they want to be undetectable and -- we all agree with that. it's so important. i think there was consensus.

i will leave with my final impression probably the biggest impact on me personally was a session done with individuals have lived with hiv/aids for more than 20 years. it was really -- i had somehow in my years of travel lost track of how those days felt and how sick those patients were. and hearing them relive the number of days they spend in the clinics, they spend in the hospitals, throughout their 20s, throughout their 30s, throughout their 40s. they were unable to work. we had mono therapy and then bitherapy. all of them made it to combination. hearing their life experiences and what an impact this is having they're in their 60s and 70s and having lost their most productive work years reminded

me why the united states turned to the huge epidemic in africa and said, we can't stand by this. we're losing all of the 25 to 45-year-olds. we experienced that. hearing their stories and really understanding that their life journey has had a tremendous impact and we all need to understand that and understand that we have a lot of patients now who live successfully with hiv but don't really have the wherewithal to retire successfully. so it really -- it renewed my commitment to understand all of the stages of the life experience from prevention of mother to child transmission all the up into our decades that we are -- not you, me, are approaching rapidly and understanding and being able to understand people's life experience and respond to them. >> thanks. chris? i wanted to thank you, too. i this is your third of these that you have done with us?

>> yes. >> you should be -- >> we will -- put it on your calendar for two years. >> two years from now, we will talk about the durban conference. i would just add to the reflections that the mh tragedy changed all of our experiences, obviously had a huge impact on the conference. to me the word that summarized the response of our community -- by mid-week we heard it was unity. this brought people together. i think this will be remembered certainly as one of the conferences if not the c conference where the divide we see got resolved. we all know we're going to need

to respond. i would say that big picture messages that came out of the conference were certainly -- debbie's talks marked a number of other presentations, the u.n. aids data, there's a consistent theme of using the resources we have strategically. more strategically, focusing on better targeting of the response, focusing on the people, u.n. aids report shows 50% of new infections going forward are predicted to be in key populations. that's an incredibly importance thing. they are relatively small proportions of our communities. but baring disproportionate burdens and excluded from services. that is a combination we have to change. we really have to work on that. so that refinement of the response i think was really a theme that emerged. if i might, if now is the right

moment, just go through a couple of the highlights from each of the tracks. of course, we have five tracks now at the conferences. while there wasn't, i would say, any one or two single big studies. there were aum -- hopefully, this will be your ten or 12 minute trip through the science. i will highlight and certainly the kaiser site is great. with track a, our basic science where there's a lot of focus on cure, obviously, the big news in advance of the course was, unfortunately, the breakthrough, after 27 months of functional remission of the mississippi child, who is now four years old and doing well on therapy, but unfortunately was not able to stay off anti-viral therapy.

the big focus, of course, is on cure and vaccines. the cure on the opening day is a masterful summary of that science. it's clear. she managed to not dumb it down and also really keep us all apprised of the science. you might want to listen to that. the big news from sort of the focus on cure is the concept of kick and kill, which is basically that you try and get hiv out of whatever latent reservoir it's hiding in and then use either immune therapy or gene therapies or perhaps other drug therapies to try and thenreactivation virus. there's a lot of information on that. there are a couple of early studies that suggest that this may be a way forward. there's clearly a consensus emerging that the best thing from a cure perspective and probably also from a clinical

perspective for individual people with hiv and almost certainly from a prevention perspective is earlier is better, earlier initiation of therapy is bert atter and peoplo likely to be the most likely to benefit from cure strategies are the people who are started on immediate heart. that, of course, includes this large pool of children worldwide who have been started shortly after birth in places where that has been the policy. that's going to be a very important area. track b, which is the clinical track, sort of great news there is that the numbers vary depending on what time frame you are cutting it at, but basically 13 million people worldwide are on anti viral therapy at this moment. with the new guidelines, of course, another equal to that number are very close to it are now eligible for therapy. so there's an enormous still

untreated population out there. more people were started in the last several years really than at any other time in the response. a lot of that, of course, due to the global fund. but also to country ownership and that whole effort. in terms of treatment areas that emerged, there was a big focus on tuberculosis. it's a great summary. had some very important findings. there's new combination therapies in co-infection that looked promising. there's an emerging area related to clinical care and smoking, particularly with thinking about copd as a smoker's condition but also as a co-morbidity in hiv. there was a lot of action on that front. and then probably track c, as

jen alluded to, which is prevention, was the area where there was the most action because there have been the most new studies and trials out. a couple of things to highlight there. first of all, the new w.h.o. guidelines on prevention, treatment and care for key affected populations were released just before the conference and then we had sessions on them. i should say that i co-chaired that guideline process. fantastic. those guidelines really made one of the strong recommendations based on quality of evidence was for consideration of the use of preexposure prophylaxis, that is prep for men who have sex with men as an additional prevention option. some of you will have seen that this got very