A Medicare policy designed to encourage certain business arrangements produced unexpected results

0:00Print servers and federal environments create risk and unnecessary complexity. Every new printer, location, or policy adds strain to infrastructure that was never built for today's demands. FedRAMP High authorized printer logic eliminates print servers with a secure cloud native, zero-trust solution designed for federal IT. With advanced security, centralized control, and simplified management, agencies can modernize print without added burden. See what secure serverless printing looks like. Visit VAsian.com to learn more. Federal Drive is presented by GEHA, Government Employees Health Association, proudly providing health and dental benefits to federal employees and their families. Visit GEHA.com. The Health and Human Services Department recently delegated one of its powers to the Center

1:04for Medicare and Medicaid Services, the Exclusion Power for Medicare and Medicaid Programs. You've just written about that. What is the Exclusion Power and why should we be paying attention here? Okay, Exclusion is a very serious power that has been historically managed by the HHS OIG. It is a, if you are subject to exclusion, it means that you are no longer allowed to participate in the Medicare and Medicaid programs. It means you are no longer to build Medicaid programs for any of your services or even provide administrative or other types of services for the Medicare and Medicaid programs. The Exclusion Power can be for the rest of your lifetime or for several years, but it effectively halts your ability to participate in Medicare and Medicaid. And this is focused on providers and suppliers, not patients. That's exactly right. This is focused on providers and suppliers.

2:05It is the power used by historically the OIG to root out individuals who have committed Medicare and Medicaid fraud, patient abuse and neglect, or have committed fraud or even misdemeanor convictions related to healthcare or other fraud. It goes so far as to stop you if you've entered into a legal kickback arrangements. Basically, if they believe you've been a bad actor and should not be in the program. Is this an authority that's used on a regular basis or lots of providers excluded from this? Or is this a pretty rare occurrence? It is, I would say, a pretty common occurrence. In this day and age, when the federal government has the ability to use a data mining and to use AI to fair it out convictions, for example, it is used pretty commonly. If you are a white collar lawyer and you know that somebody is going to get convicted for a Medicare or Medicaid fraud, a fence or abuse and neglect or something like that,

3:07you can pre-pretty sure that both federal and state exclusion will follow pretty quickly. So why delegate this? Why move it down to CMS from the HHS headquarters? Well, it's very interesting. I think that we've seen under the Trump administration a really big focus on ferring out fraud and abuse. It was a focus in prior administrations as well, but I think they're looking to have CMS have more authority. And what is interesting, there are two categories of exclusion. One is mandatory and those are mainly for convictions and fraud or patient abuse and neglect. But there are also categories called permissive exclusions where the agency can but does not have to exclude an individual. And there are two grounds CMS in particular may wield, which is the provision of unnecessary substandard services or the submission of a false or fraudulent claim. The first one, the provision of unnecessary substandard services is so

4:12broad and undefined that we're thinking that CMS, if it has a bad audit, if audits and providers and fines that they are not complying with billing requirements, that could find, that could be a grounds. So I think it is aimed at allowing CMS when it believes someone is providing services and are not to snuff or don't need billing requirements could exclude them. You mentioned that audit and I was wondering if there are, and you also mentioned data mining. Are there other ways that this misbehavior comes to light? Absolutely. So you know through audits, through convictions, but also referrals from there that could be a referral from a government agency from a from a prosecutor, it could be a referral from a competitor who says, you know, this person or even an individual, let's say it's in the long term care, it could be an individual who's not happy with their

5:13loved ones care. And so it wouldn't, it would, that would be the beginning of investigation that would then lead possibly to an explosion. Alice Harris as a partner at Maynard Nexon. Well, what's been the immediate impact of this delegation? Have you seen an increase in cases? Not immediately. I think CMS itself is working through how to go forward with this new authority. There are no regulations yet. So we are all waiting to see if there's any regulations or guidance that will be provided to the Medicare administrative contractors who administer the CMS program and how to wield this power. In the meantime, we have recommended that individuals really understand the billing and documentation requirements for billing before they drop a bill, and that providers really strengthen and establish their compliance programs to make sure that individuals who are billing and providing services are doing it correctly. And so this problem does occur in the first

6:17place. Is there a concern perhaps that this delegation tied to the administration's focus on preventing waste fraud and abuse might be a little aggressive that maybe you could get caught up in this enforcement net even if you weren't on the bad behavior list? You know, I believe it is aggressive. I think it is a drastic power. You know, I believe that in the concept of second chances in steps prior to that, let's just take our audit, for example. If somebody is not in the view of CMS passing audits, an educational step in between the audits and exclusion. In other words, getting to the root of the problem and perhaps even the imposition of the suggestion that they strengthen compliance beforehand. So I am worried about this aggressive use of this because of the

7:17amorphous and undefined standard for unnecessary substandard services. That is really I think causing some fear. Since Medicare and Medicaid are often administered by states, is there a role here for state rules and regulations to play into this process or is this purely a federal authority? It is not purely a federal authority. There are state, I believe 46-47 states have their own exclusion programs and own exclusion lists. Those are mainly used by the state governments when they identify a provider who they believe has engaged in fraud or is such a poor quality provider that they should be excluded from the state program. And when that happens, it usually triggers a federal Medicare exclusion as well. CMS as an agency has undergone a lot of workforce changes over the last 18 months, a lot of loss of workforce. Do they have the capacity, strictly speaking, to actually enforce this program? Well, I think it's again, you know,

8:23appears to be a priority for the federal government. And so even with less staff, they may be diverted from other tasks in order to start focusing on wielding the stick rather than other functions. So if you are a provider or supplier in the Medicaid space, what should you be watching? What should you be preparing for? Well, again, I think if you're in the Medicare and Medicaid space, you should really be understanding number one. What are the requirements for billing and documentation in your field? I unfortunately see a lot of providers or going into this field and not really understanding how important it is. It's like anything else. If you need to do ABC to get the reimbursement, you need to understand ABC. And that seems very simple, but I think that is the first thing to do. And then if you are a facility or an organization, the complies, I'm a big

9:25proponent of compliance and compliance programs, make sure that you are sending signals to everyone that fraud is not tolerated and give them robust training so they can be empowered to understand how to move forward. And again, avoid these problems in the first place. Alice Harris is a partner at Maynard. Nexton, thanks so much for walking us through this change in policy. It was a pleasure to be with you today, Terry. Thanks for your time. We'll post this interview at federalnewsnetwork.com slash federal drive, subscribe to the federal drive wherever you get your podcasts. What does it take to drive transformational change in large mission driven organizations? In this episode of Lessons in Leadership, former Treasury Fiscal Assistant Secretary David Lebrick sits down with WAPA CEO Shane Canfield to explore the answer to that question, drawing on nearly four decades of public service. Lebrick shares insights on how to maintain employee trust and accountability while striving for strategic leadership and operational excellence.

10:26He discusses his biggest lessons learned from modernizing major government systems and how he worked to break down silos and build high performing teams, all while staying rooted in character and integrity. Hello and welcome to the Lessons in Leadership podcast. I'm your host Shane Canfield, CEO of WAPA. Today I'm joined by David Lebrick, former Fiscal Assistant Secretary of the Treasury, the department's most senior career position, where he spent nearly four decades help oversee and modernize the federal government's financial infrastructure, including payments, collecting, debt financing, and cash management. David, welcome and thank you for being here. It's a real pleasure to be here. So let's jump right in. What does it actually take to drive transformational change inside the federal government and related, Treasury is obviously a huge organization. What did that teach you about leadership as you drove these changes?

11:27Sure. I think one of the things that you realize at time is that change and transformational change is very difficult, but it is doable. I think sometimes we don't think that we can do big things in government and yet we can. I think over the course of my career, I was enormously fortunate to work with some other really wonderful people, some of the most preeminent people in government, over the course of the last 35 years. From them, you learn a lot of really important lessons about leadership. I think early in my career, what I would tell you is that I was very much new, my interacted with political appointees as a civil servant, that you're really an advisor. And I had some really wonderful experiences advising some of really great people. My second job at Treasury, for example, was as a special assistant to J. Powell. I knew I was not going to be the most the smartest person in the room or the expert on many things that were going on, but what I did know is that I had a very good understanding about what it meant to navigate in government.

12:28Also, what it meant to advise and provide options and analysis to decision-makers. As you move up in your career and you actually take on more operational responsibility, you find out that you are a decision-maker. And when you are a decision-maker, I had a very good framework that I used throughout my career, which is as a well-edged organization, the leadership had to think about three very distinct things. One was thinking strategically about where the organization was going, not just about where it was going tomorrow and the next day, but actually into the future. The second area was that you really had to be able to deliver in the operational excellence. So if you're responsible for providing a service or a product, you can do that well. And you can think very purposefully about that. And the third area is really about people and about how you attract good people, how you retain good people, how you incent good people, and how you really treat people. And so throughout my career, I had an opportunity to see people be very effective in all three of those areas. So when it came time to

13:31do transformational change, that model worked very well. I would also say that what you learn very early on is that regardless, is that you as an individual, it takes the ability to work collectively and collaboratively with a lot of people. And so some of the things that I did, for example, which were cross-government, you realize that you really didn't have authority over many of the people that you were asking to do something different. But if you had character and competence, you could actually have trust. And so I think when people looked and said, this is someone who has capability and they have character, they will actually go and reduce the friction and actually making change. And so those collaborative relationships, that those that ability to sort of lead with purpose, I think was very important with respect to really driving transformational change. Yeah, that's an amazing perspective. I just had a chance to

14:34listen in a small room to the CEO and the chairman of the board for Mariah Corporation. And they're celebrating their 100th birthday next year. And many, most US companies don't make it to 100. And so it was, it was fascinating. Both of them were asked to what do you attribute this? And they said, both of them, with energy, it was about their people. They focused on their people and everything came back to the employees, the people that worked there, the people that they have to motivate. Do you find something similar in government? I do. I actually take, you know, oftentimes you'll hear people say people the most important asset in an organization. And there's an element of truth to that. But I also think that leadership is probably the most important aspect attribute in an organization. Because if you have the right leaders and you're using a framework like I mentioned, you're going to be really focused on getting good people in the organization. And those people will thrive. I think the thing that you find certainly in government

15:38is that federal employees are very mission driven. And they are committed. And they, you know, there's a lot of discussion about, you know, what really motivates people? Intrancyc versus extrinsic, you know, motivators. And I really do believe that, you know, when you really get a high performing organization, regardless of as private sector or public sector, it's going to be those intrinsic things which are going to actually drive employees to do great things. And so setting up those right working conditions to remind people how important they are to actually invest in their development to actually give them good feedback. You know, one of the things that is really important in an organization is if you really care about an employee and you really want to see them develop, you have to tell them not only good things, you have to tell them things they have to work on. And I think you need to set up an environment and we add a saying which is feedback is a gift and and assume noble intent in intent so that when someone gives you feedback, your first reaction

16:39shouldn't be defensive. It should be, let me make sure I can really understand why I'm getting feedback and what I can do about that. You know, I think of a story from a book called Radical Candor in which the author had gone out and spent a lot of time recruiting a new executive in the organization and thought they had a perfect match. They got to six months and the executive was struggling and they ultimately fired the executive. And at the Ex-Interview, she had turned to the executive and he said, well, I really was someone who had told me earlier on what I wasn't doing well. And I tell that story because I think it sort of says that if you're not giving good feedback to people, you've spent all this money on recruiting someone, all this time and we know it takes a lot of time to bring people on board. And if you're not giving them the benefit of it, you're not giving regular feedback to someone about what they can do better, then you potentially have a failure and you have another vacancy that you have to fill which is very costly and expensive.

17:40So I think you need to have another element of that which is in a high performing organization. If people are comfortable raising their hand when something's not going right and in my world, large-scale operations and what we did every day is something doesn't go right. It's just inevitable. And the issue within a well performing, high-performing organization is that people will raise their hand and say we have a problem and we need to fix it and the leadership is receptive to that and says, okay, what do we need to do? And then after the problem is solved, you have an obligation to go back and do lessons learned, do action learning to see, hey, what could we have done differently? How could we have avoided that problem so that you have a learning organization? It's not just that you're comfortable communicating and have trust in the organization that you can communicate openly, but also that you're learning as you go along every day to improve your operations. The very first podcast we had was Cutler Dawson who was Admiral and the Navy

18:46charge of the enterprise carrier and the fleet in the beginning of Desert Storm. And then he went on to run Navy Federal, the world's largest credit union. And it was fascinating to hear you because he talked, he used an example of a problem they had on deck with airplanes on the carrier and it was pretty serious accident that happened. And his culture was exactly what you said. You've got to talk whether you're at fault or not, whether you're partly at fault, it doesn't matter. We have to have an honest conversation about this. And that doesn't mean there weren't consequences, but at the same time that honesty has to be front and center. It really is true. And I think that you raised an interesting point, which I think sometimes the word accountability has a negative connotation. You're going to be held accountable. But also, but I would have it in a different way, which is we're accountable for high performance and we're accountable to each other to make sure that we can deliver on our mission.

19:46And that's a positive attribute along the way. And I think when organizations take that seriously, the collaboration, the teamwork, the openness, the feedback, but they also have a culture of accountability that says we do things well. We're going to actually be successful at what we do. And we all have a commitment to doing that. I think you're really a high performing organization. You've been listening to a preview edition of Lessons in Leadership. To hear the rest of this conversation and all past episodes, subscribe to Lessons in Leadership wherever you get your podcasts.