[Senate Hearing 110-309]
[From the U.S. Government Publishing Office]



                                                        S. Hrg. 110-309
 
                 MEDICAID PROVIDERS THAT CHEAT ON THEIR
                 TAXES AND WHAT SHOULD BE DONE ABOUT IT

=======================================================================


                                HEARING

                               before the

                PERMANENT SUBCOMMITTEE ON INVESTIGATIONS

                                 of the

                              COMMITTEE ON
               HOMELAND SECURITY AND GOVERNMENTAL AFFAIRS
                          UNITED STATES SENATE

                       ONE HUNDRED TENTH CONGRESS

                             FIRST SESSION

                               __________

                           NOVEMBER 14, 2008

                               __________

        Available via http://www.access.gpo.gov/congress/senate

                       Printed for the use of the
        Committee on Homeland Security and Governmental Affairs




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38-991 PDF                 WASHINGTON DC:  2008
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        COMMITTEE ON HOMELAND SECURITY AND GOVERNMENTAL AFFAIRS

               JOSEPH I. LIEBERMAN, Connecticut, Chairman
CARL LEVIN, Michigan                 SUSAN M. COLLINS, Maine
DANIEL K. AKAKA, Hawaii              TED STEVENS, Alaska
THOMAS R. CARPER, Delaware           GEORGE V. VOINOVICH, Ohio
MARK PRYOR, Arkansas                 NORM COLEMAN, Minnesota
MARY L. LANDRIEU, Louisiana          TOM COBURN, Oklahoma
BARACK OBAMA, Illinois               PETE V. DOMENICI, New Mexico
CLAIRE McCASKILL, Missouri           JOHN WARNER, Virginia
JON TESTER, Montana                  JOHN E. SUNUNU, New Hampshire

                  Michael L. Alexander, Staff Director
     Brandon L. Milhorn, Minority Staff Director and Chief Counsel
                  Trina Driessnack Tyrer, Chief Clerk


                PERMANENT SUBCOMMITTEE ON INVESTIGATIONS

                     CARL LEVIN, Michigan, Chairman
THOMAS R. CARPER, Delaware           NORM COLEMAN, Minnesota
MARK L. PRYOR, Arkansas              TOM COBURN, Oklahoma
BARACK OBAMA, Illinois               PETE V. DOMENICI, New Mexico
CLAIRE McCASKILL, Missouri           JOHN WARNER, Virginia
JON TESTER, Montana                  JOHN E. SUNUNU, New Hampshire

            Elise J. Bean, Staff Director and Chief Counsel
         Audrey Ellerbee, Congressional Fellow to Senator Levin
  Mark L. Greenblatt, Staff Director and Chief Counsel to the Minority
           Jay Jennings, Senior Investigator to the Minority
                     Mary D. Robertson, Chief Clerk


                            C O N T E N T S

                                 ------                                
Opening statements:
                                                                   Page
    Senator Levin................................................     1
    Senator Coleman..............................................     3

                               WITNESSES
                      Wednesday, November 14, 2007

Gregory D. Kutz, Managing Director, Forensic Audits and Special 
  Investigations Unit, U.S. Government Accountability Office.....     9
Linda E. Stiff, Acting Commissioner, Internal Revenue Service, 
  U.S. Department of the Treasury................................    10
Kenneth R. Papaj, Commissioner, Financial Management Service, 
  U.S. Department of the Treasury................................    12
Dennis G. Smith, Director, Center for Medicaid & State 
  Operations, Centers for Medicare and Medicaid Services, U.S. 
  Department of Health and Human Services........................    14

                     Alphabetical List of Witnesses

Kutz, Gregory D.:
    Testimony....................................................     9
    Prepared statement with attachments..........................    27
Papaj, Kenneth R.:
    Testimony....................................................    12
    Prepared statement with an attachment........................    53
Smith, Dennis G.:
    Testimony....................................................    14
    Prepared statement...........................................    58
Stiff, Linda E.:
    Testimony....................................................    10
    Prepared statement...........................................    44

                                EXHIBITS

 1. GU.S. Government Accountability Office (GAO) Report to the 
  Permanent Subcommittee Investigations, Committee on Homeland 
  Security and Governmental Affairs, U.S. Senate, MEDICAID--
  Thousands of Medicaid Providers Abuse the Federal Tax System, 
  November 2007, GAO-08-17.......................................    66

 2. GSubmission for the record regarding the Federal Contractor 
  Tax Compliance task force (FCTC)...............................   105

 3. GSubmission for the record of the U.S. Government 
  Accountability Office regarding questions posed at the November 
  14, 2007, hearing..............................................   108

 4. GSubmission for the record of the Centers for Medicare and 
  Medicaid Services regarding a question posed at the November 
  14, 2007, hearing..............................................   115

 5. GResponse to supplemental question for the record submitted 
  to Gregory D. Kutz, Managing Director, Forensic Audit and 
  Special Investigations Unit, U.S. Government Accountability 
  Office.........................................................   116

 6. GResponses to supplemental questions for the record submitted 
  to Linda E. Stiff, Acting Commissioner, Internal Revenue 
  Service, U.S. Department of the Treasury.......................   117


 MEDICAID PROVIDERS THAT CHEAT ON THEIR TAXES AND WHAT SHOULD BE DONE 
                                ABOUT IT

                              ----------                              


                      WEDNESDAY, NOVEMBER 14, 2007

                                   U.S. Senate,    
              Permanent Subcommittee on Investigations,    
                    of the Committee on Homeland Security  
                                  and Governmental Affairs,
                                                    Washington, DC.
    The Subcommittee met, pursuant to notice, at 3:38 p.m., in 
Room SD-342, Dirksen Senate Office Building, Hon. Carl Levin, 
Chairman of the Subcommittee, presiding.
    Present: Senators Levin and Coleman.
    Staff Present: Elise J. Bean, Staff Director and Chief 
Counsel; Mary D. Robertson, Chief Clerk; Audrey Ellerbee, 
Congressional Fellow to Senator Levin; Mark L. Greenblatt, 
Staff Director and Chief Counsel to the Minority; Jay Jennings, 
Senior Investigator to the Minority; Sharon Beth Kristal, 
Counsel to the Minority; Alan Kahn, Law Clerk; Jonathan Port, 
Intern; Peg Gustafson and Jonathan Scanlon (Senator McCaskill); 
Adam Pullano, Intern; and Andrew McKechnie (Senator Coleman).

               OPENING STATEMENT OF SENATOR LEVIN

    Senator Levin. Good afternoon, everybody. Today's hearing 
is the fifth in a series before this Subcommittee on Federal 
contractors who get paid with taxpayer dollars but fail to pay 
their taxes. Prior hearings have exposed as tax delinquents 
over 100,000 defense and civilian contractors and Medicare 
service providers who collectively owe billions in unpaid 
taxes.
    The spotlight today is on the Medicaid program, in 
particular on the doctors, nursing homes, and other medical 
providers who get paid with taxpayer dollars through Medicaid, 
but have failed to meet their tax obligations. A review of just 
seven States has identified nearly 30,000 Medicaid providers 
who collectively owe delinquent taxes that date as far back as 
10 years, and which collectively exceed $1 billion. Most of 
these unpaid taxes consist of payroll taxes that the Medicaid 
providers withheld from their employees' paychecks but did not 
remit to the Federal Government, and that is a crime.
    Medicaid is a key Federal program that helps fund health 
care for America's poor. The vast majority of physicians and 
companies who participate in the Medicaid program are true 
public servants who deserve our admiration and gratitude. But a 
small portion of Medicaid providers are benefiting from the 
program while taking advantage of honest taxpayers. These 
Medicaid providers are putting taxpayer dollars in their 
pockets with one hand, while using the other to stiff Uncle Sam 
by not paying their taxes.
    Federal programs exist to stop this type of abuse. One key 
program is the Federal Payment Levy Program, which was 
established about 10 years ago to enable the Federal Government 
to identify Federal payments being made to tax delinquents and 
to authorize the withholding of a portion of those payments to 
apply to the person's tax debt.
    Last year, the tax levy program collected a total of about 
$343 million in unpaid taxes from all types of Federal 
programs; only $47 million, or less than 15 percent, came from 
Federal contract payments. In light of the billions of dollars 
in unpaid taxes owed by Federal contractors, $47 million is 
still far, far too low. More needs to be done to cut the red 
tape hindering the tax levy program.
    The tax delinquents we are tackling today are the tax 
dodgers taking advantage of the Medicaid program. Last year, 
the Subcommittee asked the Government Accountability Office 
(GAO) to estimate the number of Medicaid providers with unpaid 
taxes.\1\ The GAO examined records in seven states that 
together account for roughly 40 percent of the total Medicaid 
contract dollars spent by the Federal Government each year. In 
those seven States, by comparing Medicaid payment records to 
the IRS list of delinquent taxpayers, the GAO was able to 
identify about 30,000 medical providers, about 5 percent of the 
total number of Medicaid providers in those States, whose 
unpaid taxes were about $1 billion.
---------------------------------------------------------------------------
    \1\ See Exhibit 1, which appears in the Appendix on page 66.
---------------------------------------------------------------------------
    In addition, the GAO identified 25 examples of blatant tax 
dodging, each of which involved a medical service provider who 
received at least $100,000 in Medicaid payments last year. The 
GAO identified one physician, for example, who owes over 
$300,000 in unpaid Federal taxes and claims ``limited ability 
to pay taxes.'' That is his claim. Yet the GAO was able to 
determine that this same physician owns residential property 
worth over $1 million, received over $100,000 in Medicaid 
payments last year, and also received tens of thousands of 
dollars in Medicare payments.
    In another instance, the GAO identified a nursing home that 
owes approximately $2 million in back taxes, but received 2006 
Medicaid payments totaling $6 million. The same nursing home 
has also been cited by the State for jeopardizing the health 
and safety of its patients. A third example involves a dentist 
who received $200,000 in Medicaid payments last year but who 
has not made any Federal tax payments in several years.
    The GAO also determined that not a single Medicaid tax 
delinquent has had a single Medicaid payment screened under the 
tax levy program. When we asked why, we learned that the entire 
Medicaid program--all $185 billion paid by the Federal 
Government last year--is exempt from the tax levy program 
because Medicaid payments are not considered ``Federal 
payments.'' And the tax levy program, as of right now, is 
authorized to withhold funds only from ``Federal payments.'' 
There is no provision in the law for tax levies to be applied 
to payments that are a mix of Federal and State dollars, which 
is what Medicaid payments are.
    So one of the questions that we would like to examine today 
is: In light of the tax dodging going on by providers who 
receive payments from the Medicaid program, could the tax levy 
law be amended to allow the Federal Government to attach a 
portion of Medicaid payments that are being made to tax 
delinquents? And we would like to look at whatever solutions 
might be available to that problem.
    I hope that the agencies that are gathered here today--the 
GAO, the IRS, FMS and CMS--will lend us their expertise to help 
analyze the problem and identify possible solutions.
    Again, the vast majority of Medicaid providers are law-
abiding citizens who pay their taxes on time. In too many 
cases, these honest and hard-working providers have to compete 
against a small number of Medicaid providers who actually gain 
a competitive edge by not paying or by delaying payment on 
their taxes. It is long past time to find a way to withhold 
Medicaid payments from those providers who are shortchanging 
the very taxpayers who are supplying their paychecks and, 
thereby, forcing taxpayers who pay their taxes on time to 
shoulder the taxes that they--the people who are not paying 
their taxes--are shirking. We need to figure out how to enlist 
the tax levy program to stop these abuses.
    Senator Coleman got the ball rolling on these hearings into 
tax delinquent Federal contractors, and this series of hearings 
is a result of that effort. We commend him for that, and we 
commend our staffs who have always worked closely together on 
this issue and all the other issues we work on, and we thank 
them for their efforts as well.
    Senator Levin. Senator Coleman.

              OPENING STATEMENT OF SENATOR COLEMAN

    Senator Coleman. Thank you, Mr. Chairman, and I want to 
start at the outset by thanking you for holding this hearing. 
This Subcommittee has focused on the issue of tax cheats and 
those who avoid their tax obligations because all the rest in 
the end who are paying our taxes, are living by following the 
rules, we pay a price for that. And so I want to thank the 
Chairman and his staff. Our staffs have worked together, and it 
has been the hallmark of this Subcommittee, and so I start by 
expressing my appreciation.
    Today we turn our attention to a disturbing problem: 
Medicaid providers that are cheating on their taxes. We did 
Medicare last time. As the Chairman has indicated, at our 
request GAO examined whether Medicaid providers are cheating on 
their taxes. The results of their report came back and found 
that more than 30,000 Medicaid providers owe back taxes of more 
than $1 billion.\1\ That is with a ``b'' and 9 zeros behind the 
number. To make matters worse, that estimate understates the 
problem because GAO's analysis only covered seven States, which 
represented only 43 percent of Medicaid expenditures. So the 
potential is actually much, much larger--potentially twice as 
much, 60,000 providers, could owe $2 billion in unpaid Federal 
taxes.
---------------------------------------------------------------------------
    \1\ See Exhibit 1, which appears in the Appendix on page 66.
---------------------------------------------------------------------------
    These are not your everyday tax cheats. For starters, they 
receive billions of dollars every year from the Federal 
Government. In one case, a facility received $39 million from 
Medicaid in 2006 alone. So even though they make a good portion 
of their living from the Federal Government, they refuse to pay 
their fair share of taxes. It adds insult to injury that these 
tax deadbeats are actually paid enormous amounts of money every 
year from American tax coffers. They are truly biting the hand 
that feeds them.
    Even worse, they are abusing their employees. The report 
finds that 56 percent of the unpaid taxes are payroll taxes. So 
keep in mind that payroll taxes include withholdings from their 
employees' wages for Social Security, Medicare, and individual 
income taxes. These providers, like all employers, hold this 
money in trust for their employees and are required to forward 
it to the IRS. Rather than following the law after collecting 
the money, these providers diverted the money for their own 
personal gain. Many of the owners of these businesses used 
their employees' payroll taxes to buy luxury cars, boats, and 
multi-million-dollar properties and homes, even though they 
owed hundreds of thousands--if not millions--of dollars in 
unpaid taxes. What is more, GAO's study revealed that Medicaid 
providers also owe more than $100 million in other debts, such 
as child support, student loans, and State tax debts.
    The Chairman mentioned a couple cases. I will mention just 
two others.
    One was a nursing home facility that received more than $39 
million in Medicaid payments in fiscal year 2006, even though 
it owes more than $16 million in taxes. The majority of that 
tax debt is payroll taxes. The business was fined for quality-
of-care violations just a couple of years ago. One of its 
executives withdrew more than $100,000 in cash at casinos at 
the same time he was not paying the nursing home's taxes. 
Multi-million-dollar Federal and State tax liens are 
outstanding against this business.
    Perhaps the most egregious illustration is a nursing home 
business that received $25 million in payments in 2006 and owed 
more that $14 million in back taxes. Court documents reveal 
that while the business owed this tremendous tax debt, the 
owner of the business bought a 10,000-square-foot home worth 
more than $2 million and spent tens of thousands of dollars on 
crystal chandeliers, a 132-piece set of fine Bavarian china, 
and oriental rugs. The owner used the business's money to pay 
for a housekeeper, a nanny, monthly payments to a parent who 
did not work for the company, a sailboat, and jet skis. And we 
are not done yet. The report also showed that the owner enjoyed 
gambling trips to Las Vegas and Reno. And, in fact, on one of 
these trips, he purchased a $16,000 Rolex on the day before a 
required Federal tax payment was due and not paid.
    Unfortunately, these are just the tip of the iceberg. This 
report establishes that there are thousands and thousands of 
other tax cheats just like them in the Medicaid program. I will 
repeat what the Chairman said. To be clear, this is not an 
indictment of all Medicaid providers or of the Medicaid program 
as a whole. The vast majority of Medicaid providers are 
honorable, law-abiding businesses that are helping the Nation's 
underserved communities. We appreciate their service and admire 
their dedication. They are actually put at a competitive 
disadvantage by tax cheats who get away without living up to 
paying their tax obligations.
    But there is a multi-billion-dollar problem here. In a time 
requiring fiscal discipline, these billions could be put 
towards our homeland security, our children's education, job 
training programs, or a host of other programs that serve 
America's needs. If the Federal Government levied the Medicaid 
payments in these seven States alone, we could recoup up to 
$160 million a year. Levying payments all over the United 
States might recover hundreds of millions in back taxes. Even 
for the Federal Government, that is a substantial sum of money.
    Our hearing today will examine the scope of the problem and 
how we can address it. We have found over the course of the 
Subcommittee's investigation that there is no easy fix to this 
problem. The Medicaid payment mechanism is complex, and serious 
legal obstacles stand in the way. But we have been down this 
road before. Over the course of our 4-year inquiry into tax 
delinquent Federal contractors, we--along with the Federal 
Contractor Tax Compliance Task Force--have overcome numerous 
seemingly insurmountable hurdles. The task force has worked 
with this Subcommittee to resolve several thorny problems that 
inhibit the Federal Payment Levy Program, and it is continuing 
its work on a number of additional problems. I appreciate their 
diligence and I applaud their success. I call upon the task 
force--specifically the IRS, FMS, and CMS--to study this issue 
and recommend changes that would recover unpaid taxes from 
Medicaid payments. I ask for their commitment to work together 
and with this Subcommittee to fix the problem. In light of our 
collective ability to overcome serious problems in the past and 
the success achieved to date, I am confident we can work 
together to solve these thorny problems once and for all.
    As we move forward, however, I would like to publicly 
express my concern that this Subcommittee has not received full 
cooperation from CMS. In July, Acting Administrator Kerry Weems 
said that increased oversight would be the hallmark of his 
tenure at CMS. In fact, I believe he stated at one of his 
confirmation hearings, ``If confirmed, I will intensify CMS 
oversight and I expect you to hold me responsible.''
    Well, the proof is in the pudding, and I ask CMS to live up 
to Mr. Weems's goals. Throughout our investigations, CMS' 
assistance can be described--and I think it is a fair 
description--as ``begrudging'' at best. On several occasions, 
CMS has treated bipartisan requests from this Subcommittee as 
Freedom of Information Act applications. Requests from GAO, on 
behalf of this Subcommittee, have been met at times with 
resistance and uncooperative behavior. We have had numerous 
other problems that have hindered and delayed the 
Subcommittee's efforts. In short, we really do need to do 
better.
    In fact, this morning CMS challenged GAO's report, saying, 
``We believe that the stated goals of this investigation were 
based on misconceptions about the authority and 
responsibilities of the Medicaid program.'' Make no mistake. 
The goal of this investigation is clear: To identify tax abuse 
among government providers and fix the problem. GAO and this 
Subcommittee have a clear understanding of this issue. We 
understand its complexity. We recognize that there are 
intricate legal obstacles. We recognize that there are 
technical and procedural hurdles to overcome.
    But at the same time, we recognize that Federal providers 
and contractors should not be given a free pass on their tax 
obligations--whether they are contractors for DOD or providers 
of Medicare. Thousands of Medicaid providers should not be 
exempt from paying their taxes. The government has a unique 
opportunity to levy payments to these providers before they are 
made, and it is incumbent on us to figure out the most 
efficient and effective way of doing it without undermining 
quality of care. And I believe the two goals are not 
inconsistent, that we can provide quality of care and at the 
same time folks can live up to their tax obligations.
    I think it is important to understand that what we are 
doing affects the quality of care for our most vulnerable 
citizens because the report suggests that outstanding tax debt 
may be an indicator of low-quality medical care. The 5 percent 
of providers who cheat on their taxes frequently have other 
problems, such as health care-related violations. It is not in 
the interest of the poor to have low-quality providers in the 
Medicaid system. Therefore, rather than undermining Medicaid, 
identifying these tax cheats could strengthen the system.
    I reiterate my call for CMS to work cooperatively with the 
IRS and FMS to find a resolution to this problem. I look 
forward to reviewing your collective recommendations. If 
legislative changes are needed, we will consider them; if the 
Federal Government may need to assist the States in order to 
get their participation in the continuous levy program, we will 
evaluate that as well. Again, the goal is to improve the 
functioning of our government, and we need CMS to be a 
productive and willing partner in that effort.
    I look forward to the testimony of today's witnesses. Thank 
you, Mr. Chairman.
    [The prepared statement of Senator Coleman follows:]
                  OPENING STATEMENT OF SENATOR COLEMAN
    Good afternoon and welcome to today's hearing. At the outset, I 
would like to commend our Chairman, Senator Levin, for holding this 
hearing. Like all of the Subcommittee's investigations, this has been a 
bipartisan effort every step along the way. I appreciate your support 
throughout this investigation.
    Today, we turn our attention to a disturbing problem--Medicaid 
providers that are cheating on their taxes. At our request, GAO 
examined whether Medicaid providers are cheating on their taxes and 
found that more than 30,000 Medicaid providers owe back-taxes of more 
than $1 billion. To make matters worse, that estimate understates the 
problem because GAO's analysis covered only seven States, which 
represented only 43 percent of Medicaid expenditures. So, the problem 
is actually much, much larger--potentially as many as 60,000 providers 
owe $2 billion in unpaid Federal taxes.
    These are not your everyday tax-cheats. For starters, they receive 
billions of dollars every year from the Federal Government--one of 
these deadbeats received $39 million from Medicaid in 2006 alone. Even 
though they make their living from the Federal Government, they refuse 
to pay their fair share of taxes. It adds insult to injury that these 
tax deadbeats are actually paid enormous amounts of money every year 
from American tax coffers. They are truly biting the hand that feeds 
them.
    Even worse, they are abusing their employees. The report finds that 
56 percent of the unpaid taxes are payroll taxes. Keep in mind that 
payroll taxes include withholdings from their employees' wages for 
Social Security, Medicare, and individual income taxes. These 
providers, like all employers, hold this money in trust for their 
employees and are required to forward them to the IRS. Rather than 
following the law, however, these providers diverted the money for 
their own personal gain. Many of the owners of these businesses used 
their employees' payroll taxes to buy luxury cars, boats, and multi-
million dollar properties and homes, even though they owed hundreds of 
thousands--if not millions--of dollars in unpaid taxes. What's more, 
GAO's study also revealed that Medicaid providers also owe more than 
$100 million in other debts, such as child support, student loans, and 
State tax debts.
    To get a sense of the problem, let's review a couple of troubling 
cases:

      One nursing home facility received more than $39 million 
in Medicaid payments in fiscal year 2006, even though it owes more than 
$16 million in taxes. The majority of that tax debt is payroll taxes. 
The business was fined for quality of care violations just a couple of 
years ago. One of its executives withdrew more than $100,000 in cash at 
casinos at the same time he was not paying the nursing home's taxes. 
Multi-million dollar Federal and State tax liens are outstanding 
against the business.

      Perhaps the most egregious illustration is a nursing home 
business received $25 million in payments in 2006 and owed more that 
$14 million in back taxes. Court documents reveal that, while the 
business owed this tremendous tax debt, the owner of the business 
bought a 10,000-square foot home worth more than $2 million and spent 
tens of thousands on crystal chandeliers, 132-piece set of fine 
Bavarian china, and oriental rugs. The owner also used the business's 
money to pay for a housekeeper, a nanny, monthly payments to a parent 
who did not work for the company, a sailboat and jet-skis. And we're 
not done yet--the owner also enjoyed gambling trips to Las Vegas and 
Reno and went on vacations to Hawaii. During this trip to Hawaii, the 
owner purchased a $16,000 Rolex on the day before a required Federal 
payment was due.

    Unfortunately, these are just the tip of the iceberg--this report 
establishes that there are thousands and thousands of other tax-cheats 
just like them in the Medicaid program. To be clear, this hearing is 
not an indictment of all Medicaid providers or of the Medicaid program 
as a whole. The vast majority of Medicaid providers are honorable, law-
abiding businesses that are helping the Nation's underserved 
communities; we appreciate their service and admire their dedication.
    But there is a $2 billion problem here. In a time requiring strict 
fiscal discipline, these billions could be put towards our homeland 
security, our children's education, job training programs, or a host of 
other programs that serve America's needs. If the Federal Government 
levied the Medicaid payments in those seven States alone, we could 
recoup up to $160 million every year. Levying payments all over the 
United States might recover hundreds of millions in back taxes. Even 
for the Federal Government, that is a substantial sum of money.
    Our hearing today will examine the scope of the problem and how we 
can address it. We have found over the course of the Subcommittee's 
investigation that there is no easy fix to this problem--the Medicaid 
payment mechanism is complex and serious legal obstacles stand in our 
way. But we have been down this road before. Over the course of our 4-
year inquiry into tax-delinquent Federal contractors, we--along with 
the Federal Contractor Tax Compliance Task Force--have overcome 
numerous seemingly insurmountable hurdles. The Task Force has worked 
with this Subcommittee to resolve several thorny problems that inhibit 
the Federal Payment Levy Program and it is continuing its work on a 
number of additional problems. I appreciate their diligence and I 
applaud their success. I call upon the Task Force--specifically, the 
IRS, FMS, and CMS--to study this issue and recommend changes that would 
recover unpaid taxes from Medicaid payments. I ask for their commitment 
to work together and with this Subcommittee to fix the problem. In 
light of our collective ability to overcome serious problems in the 
past and the success achieved to date, I am confident we can work 
together to solve these thorny problems as well.
    As we move forward, however, I would like to publicly express my 
concern that this Subcommittee has not received full cooperation from 
CMS. In July, Acting Administrator Kerry Weems said that increased 
oversight would be hallmark of his tenure at CMS. In fact, I believe he 
stated at one of his confirmation hearings ``If confirmed, I will 
intensify CMS oversight and I expect you to hold me responsible.'' 
Well, the proof is in the pudding, and I ask CMS to live up to Mr. 
Weems's goals. Throughout our investigations, CMS's assistance has been 
begrudging at best. For example, on several occasions, CMS has treated 
bipartisan requests from this Subcommittee as FOIA applications. 
Requests from GAO, on behalf of this Subcommittee, have been met with 
resistance and uncooperative behavior. We have had numerous other 
problems that have hindered and delayed the Subcommittee's efforts. In 
short, we need to do better.
    In fact, CMS this morning challenged GAO's report, saying ``we 
believe that the stated goals of this investigation were based on 
misconceptions about the authority and responsibilities of the Medicaid 
program.'' Make no mistake: the goal of this investigation is clear--to 
identify tax abuse among government providers and fix the problem. GAO 
and this Subcommittee have a clear understanding of the issue; we 
understand its complexity. We recognize that there are intricate legal 
obstacles. We recognize that there are technical and procedural hurdles 
to overcome.
    But at the same time, we recognize that Federal providers and 
contractors should not be given a free pass on their tax obligations--
whether they are contractors for DOD or providers in Medicare. 
Thousands of Medicaid providers should not be exempt from paying their 
taxes. The government has a unique opportunity to levy payments to 
these providers before they are made and it is incumbent on us to 
figure out the most efficient and effective way of doing so.
    We also recognize that this affects the quality of medical care for 
our most vulnerable citizens; the evidence suggests that outstanding 
tax debt may be an indicator of low-quality medical care. The 5 percent 
of providers who cheat on their taxes frequently have other problems, 
such as health care-related violations. It is not in the interest of 
the poor to have low-quality providers in the Medicaid system. 
Therefore, rather than undermining Medicaid, identifying these tax-
cheats could strengthen it.
    I reiterate my call for CMS to work cooperatively with the IRS and 
FMS to find a resolution to this problem. I look forward to reviewing 
your collective recommendations. If legislative changes are needed, we 
will consider them; if the Federal Government may need to assist the 
States in order to get their participation in the continuous levy 
program, we will evaluate that as well. Again, the goal is to improve 
the functioning of our government and we need CMS to be a productive 
and willing partner in that effort.
    I look forward to the testimony of our witnesses.

    Senator Levin. Thank you very much, Senator Coleman.
    Let me now welcome our panel of witnesses for this 
afternoon's hearing: Gregory Kutz, Managing Director of the 
Forensic Audits and Special Investigations Unit at the 
Government Accountability Office; Linda Stiff, the Acting 
Commissioner of the Internal Revenue Service; Kenneth Papaj, 
the Commissioner of the Financial Management Service at the 
Department of the Treasury; and Dennis Smith, Director of the 
Center for Medicaid & State Operations at the Centers for 
Medicare and Medicaid Services at the Department of Health and 
Human Services.
    We appreciate all of your being with us this afternoon. We 
look forward to your testimony.
    Pursuant to Rule VI, all witnesses who testify before this 
Subcommittee are required to be sworn, and at this time I would 
ask all of you to please stand and raise your right hand. Do 
you swear that the testimony you will give before this 
Subcommittee will be the truth, the whole truth, and nothing 
but the truth, so help you, God?
    Mr. Kutz. I do.
    Ms. Stiff. I do.
    Mr. Papaj. I do.
    Mr. Smith. I do.
    Senator Levin. Thank you.
    We will be using a timing system today. Approximately 1 
minute before the red light comes on, you will see the light 
change from green to yellow, giving you an opportunity to 
conclude your remarks. The written testimony of each of you 
will be printed in the record in its entirety. We ask that you 
limit your oral testimony to no more than 5 minutes.
    Mr. Kutz, we will have you go first, followed by Ms. Stiff, 
Mr. Papaj, and then Mr. Smith. After we have heard all of your 
testimony, we will turn to questions. So, Mr. Kutz, welcome.

 TESTIMONY OF GREGORY D. KUTZ,\1\ MANAGING DIRECTOR, FORENSIC 
    AUDITS AND SPECIAL INVESTIGATIONS UNIT, U.S. GOVERNMENT 
                     ACCOUNTABILITY OFFICE

    Mr. Kutz. Mr. Chairman and Ranking Member Coleman, thank 
you for the opportunity to discuss Medicaid providers with tax 
problems.
---------------------------------------------------------------------------
    \1\ The prepared statement of Mr. Kutz with attachments appears in 
the Appendix on page 27.
---------------------------------------------------------------------------
    In March, I testified that Medicare physicians and other 
suppliers were abusing the Federal tax system with little or no 
consequence. At your request, we have expanded our 
investigation of tax abuse to Medicaid providers. My testimony 
has two parts: First I will discuss our findings and, second, 
key policy and program issues.
    First, we found that over 30,000, or 5 percent, of Medicaid 
providers in seven States had over $1 billion of delinquent 
Federal taxes. These seven States represent about 43 percent of 
total Medicaid disbursements. To put a face on this issue, as 
you mentioned, we investigated 25 Medicaid cases from these 
seven States. For all 25 cases, we found abusive and criminal 
activity related to the Federal tax system. Seventeen of these 
cases were businesses with unpaid payroll taxes. As you both 
mentioned, willful failure to remit payroll taxes to the IRS is 
a felony.
    For 2006, these 25 providers received $88 million of 
Medicaid payments while at the same time having $52 million of 
delinquent Federal taxes. Many of these individuals accumulated 
substantial personal wealth, in part due to Medicaid, at the 
same time they failed to pay their Federal taxes. The 
posterboard shows examples of some of the homes and luxury 
vehicles owned by these individuals.\2\
---------------------------------------------------------------------------
    \2\ The chart referred to by Mr. Kutz appears in the Appendix on 
page 42.
---------------------------------------------------------------------------
    In addition to these 25 cases, we separately found the 
owner of a nursing home that was recently convicted for payroll 
tax fraud. This business received $25 million of Medicaid 
payments while at the same time having $14 million of 
delinquent Federal taxes.
    As Senator Coleman mentioned, at the same time this 
individual failed to pay payroll taxes, they bought a 10,000-
square-foot home for over $2 million and a $16,000 Rolex watch 
one day before the payroll tax deposit was due.
    Our current and past investigations have shown that failure 
to pay Federal taxes is not the only problem these individuals 
have. Let me use the posterboard to walk you through four other 
themes from our cases.\3\
---------------------------------------------------------------------------
    \3\ The chart referred to by Mr. Kutz appears in the Appendix on 
page 43.
---------------------------------------------------------------------------
    First, as Senator Coleman mentioned, inadequate medical 
care. We found patient abuse, quality-of-care violations, and a 
number of malpractice lawsuits.
    Second, substantial other debt. Sixteen of our cases had 
State tax debt, and others had unpaid or delinquent student 
loans and other Federal debts.
    Third, criminal activity. Several individuals were 
convicted of larceny and income tax evasion. Others were 
investigated for money laundering, mail fraud, and cocaine 
possession.
    And, fourth, suspicious cash transactions. Several 
individuals had large cash transactions, including one 
individual with well over $100,000 of gambling transactions.
    These outrageous cases lead to my second point. What is 
being done about tax frauds that are operating in the Medicaid 
program? Unfortunately, the answer to that is nothing. Federal 
law does not prohibit providers with unpaid taxes from 
enrolling in or billing Medicaid.
    In a written response to our report, CMS expressed concerns 
about the tone and language of our report and implications that 
they have any responsibility or authority to screen providers 
for tax debt. Our report clearly states that CMS is not 
required to do anything. However, we are concerned that 
fraudsters like the ones I just mentioned are currently 
operating within the Medicaid program. We believe that 
Congress, CMS, and the States should consider options to 
prevent the more egregious cases I discussed from participating 
in Medicaid. All options should ensure Medicaid participants 
are not harmed. Ridding Medicaid of the 26 fraud cases that I 
have described would be a positive step for program integrity.
    At the back end of the process, we have the levy process, 
which was mentioned by both Senator Levin and Senator Coleman. 
We estimate that for fiscal year 2006, an effective, continuous 
tax levy would have resulted in the collection of between $70 
and $160 million of delinquent Federal taxes for these seven 
States. To date, there has been no continuous levy of Medicaid 
in any States, and, again, Senator Coleman, you mentioned that 
was because IRS has determined that these are not Federal 
payments--a key requirement for the levy program.
    In conclusion, the good news is that the vast majority of 
Medicaid providers pay their Federal taxes. However, our work 
has shown that thousands of these providers have taken 
advantage of the opportunity to avoid paying over $1 billion of 
Federal taxes. Our case studies show the enrichment of tax 
fraudsters being bankrolled by State and Federal Medicaid 
payments. Isn't it ironic that a program designed to provide 
health care to the poor is actually being used to line the 
pockets of these tax fraudsters?
    Senator Coleman, this ends my statement. I look forward to 
your questions.
    Senator Coleman [presiding]. Thank you, Mr. Kutz. Ms. 
Stiff.

  TESTIMONY OF LINDA STIFF,\1\ ACTING COMMISSIONER, INTERNAL 
        REVENUE SERVICE, U.S. DEPARTMENT OF THE TREASURY

    Ms. Stiff. Good afternoon, Chairman Levin, Ranking Member 
Coleman, and Members of the Subcommittee. I am pleased to 
update you on the progress we have made since your hearing last 
March on the Medicare issue, as well as to discuss the 
possibility of including Medicaid providers in the continuous 
levy program. I also want to thank this Subcommittee for its 
continued interest in the broad issue of using the Federal 
Payment Levy Program (FPLP) as a means of collecting tax debt. 
I am pleased to report that total revenue collected through the 
FPLP has increased from $89 million in fiscal year 2003 to $345 
million in fiscal year 2007, nearly a four-fold increase. Much 
of the progress we have made in the past 4 years has been the 
direct result of the interest and support of the Subcommittee 
Members and its staff.
---------------------------------------------------------------------------
    \1\ The prepared statement of Ms. Stiff appears in the Appendix on 
page 44.
---------------------------------------------------------------------------
    During the hearing last March, we explained that we had 
just determined that payments to Medicare providers were indeed 
Federal payments for the purposes of the FPLP, and that we were 
beginning to work with the CMS and the FMS to determine how to 
bring these providers under the continuous levy program.
    CMS joined the Federal Contractor Tax Compliance Task Force 
to assist in the development of a pilot program to incorporate 
Medicare provider payments into the FPLP. That pilot program is 
tentatively scheduled to go into operation in 2008 and will 
levy Medicare payments disbursed through CMS' centralized 
accounting system. This is a systemic process whereby FMS will 
match information about CMS' payments, on a daily basis, 
against the tax debts included in the FPLP. FMS will provide 
information back to CMS when there was a match, and CMS will 
levy the payments.
    We are on track to implement the matching process in 2008 
for contractors that are currently utilizing the CMS system. We 
anticipate full and complete implementation during fiscal year 
2011.
    Also at the March hearing, GAO referred to us 40 cases with 
evidence that certain Medicare providers may be guilty of 
abusive and/or potentially criminal activity relative to 
Federal income and/or employment taxes. My written statement 
provides a detailed report on the progress we have made in 
dealing with these cases.
    On track with the latest GAO investigation that is the 
subject of this hearing, the task force has now sought to 
determine if payments to Medicaid providers might also be 
included in the FPLP. Unfortunately, we have been advised by 
Counsel that the FPLP, as currently structured is not a tool 
that can be used to collect payments made by States to Medicaid 
providers. Counsel weighed various factors relating to the 
structure and operation of the Medicaid program, concluding 
that the payments do not meet the criteria established to be 
considered Federal payments. This means that we must use 
alternative enforcement tools to pursue Medicaid providers that 
are delinquent on their taxes.
    After this hearing, GAO will refer to us 25 additional 
cases that it discovered in its audit. We will review these 
cases carefully and take appropriate action, as we have on the 
previous cases which GAO referred to us. However, I would note 
that a cursory review of these 25 cases, based on the 
information provided in the GAO report, indicates that the 
taxpayers involved in these cases are not strangers to IRS 
enforcement. The profile of each of these providers confirms 
that the IRS has sought enforcement actions against virtually 
all of them. In some cases, that action involved a lien against 
the provider or an effort to apply the Trust Fund Recovery 
Penalty. In some cases, the provider was part of the FPLP levy, 
although not for Medicaid payments.
    I would be remiss if I did not mention one final issue that 
certainly has an impact on our ability to deal with these 
issues. It is critical that the IRS' fiscal year 2008 budget 
request be fully funded. We need those resources to continue 
our efforts in the very areas we are discussing here today.
    Thank you again, Mr. Chairman, for your efforts and for the 
opportunity to be here this afternoon. I will be happy to 
respond to any questions that you may have.
    Senator Coleman. Thank you, Ms. Stiff. Mr. Papaj.

   TESTIMONY OF KENNETH R. PAPAJ,\1\ COMMISSIONER, FINANCIAL 
      MANAGEMENT SERVICE, U.S. DEPARTMENT OF THE TREASURY

    Mr. Papaj. Thank you, Chairman Levin, Ranking Member 
Coleman, and Subcommittee Members. Thank you for inviting me 
here to testify today. I am pleased to have this opportunity to 
report on the success of the FMS' debt collection program and 
our recent accomplishments and ongoing plans to further improve 
the Federal Payment Levy Program. I would like to thank the 
Members of this Subcommittee and your staffs for your 
continuing interest in and support of these important efforts.
---------------------------------------------------------------------------
    \1\ The prepared statement of Mr. Papaj with an attachment appears 
in the Appendix on page 53.
---------------------------------------------------------------------------
    FMS operates a government-wide debt collection program that 
collects both tax and non-tax debts owed to Federal agencies 
and certain debts owed to States. I am pleased to report that 
in fiscal year 2007, the program brought in record-breaking 
collections of $3.76 billion, $1.7 billion of which was for 
child support. Of the $3.76 billion, Federal tax debt 
collections totaled approximately $345 million, an increase of 
$42 million, or 14 percent, over fiscal year 2006 collections. 
As shown on the attached chart,\2\ collections have shown a 
steady rise over the last 4 years. And since the inception of 
the program in 1996, we have collected over $31.5 billion in 
delinquent debt that would otherwise not have been collected.
---------------------------------------------------------------------------
    \2\ The chart referred to by Mr. Papaj appears in the Appendix on 
page 57.
---------------------------------------------------------------------------
    With regard to Federal contractors who owe delinquent 
taxes, the number of levies against Federal vendor payments 
increased in fiscal year 2007 by 11 percent. Collections from 
Federal contractors totaled $47.4 million in 2007 and over $1.1 
billion in tax debts have been collected since the inception of 
the levy program. And this number reflects only the collections 
received directly through FMS' Federal Payment Levy Program.
    Notwithstanding these record collections, we realize there 
is always room for improvement, and we strive to achieve that.
    Since the last Subcommittee meeting in March, significant 
developments have taken place. First, we have added additional 
payment types to the program. In June of this year we added 
payments issued by the Army Corp of Engineers to both the 
offset and levy programs. In October, FMS began offsetting 
Railroad Retirement Board payments with $844,000 collected in 
the first 2 months. We will soon add those payments to the levy 
program once programming changes are complete. In August, we 
implemented a process to ensure that delinquent taxpayers are 
not able to bypass the levy process by receiving Federal 
payments via Fedwire, which is a same-day payment mechanism. 
Delinquent taxpayers are now blocked from receiving Fedwire 
payments and must receive their payment through another 
mechanism that is subject to levy.
    Next, we have put in place reciprocal agreements with the 
States of Maryland and New Jersey to collect each other's debt. 
Since offsets began in July, we have collected $11.8 million of 
debt owed to Maryland and New Jersey, and those two States have 
collected $439,000 of debt owed to the Federal Government.
    Additionally, we continue to work with IRS to increase the 
number and dollar amount of tax debt that is activated for 
levy. The amount of tax debts activated for levy has increased 
from $53.1 billion in fiscal year 2006 to $62.7 billion in 
fiscal year 2007. This represents about 51 percent of the tax 
debt IRS has referred and is an increase of 6 percent from 
fiscal year 2006. To increase this number even further, the 
Administration has proposed a legislative change that would 
allow IRS to forego the due process that is currently required 
prior to levy and allow instead for post levy due process under 
certain circumstances. We believe this would be particularly 
helpful in ensuring that we do not miss the opportunity to levy 
payments to contractors which are often one-time, non-recurring 
payments.
    We also continue to work to ensure that payments from 
various systems used for making payments to contractors are 
subject to levy. The latest system to be added, known as the 
Automated Clearing House-Corporate Trade Exchange system, is on 
target for implementation by the end of December.
    We are ready to conduct testing with the U.S. Postal 
Service to incorporate their payments into the levy program, 
and we are on target for full implementation by the end of this 
year.
    At the March hearing, this Subcommittee brought to light 
the important issue of Medicare providers who owe significant 
amounts of tax debt, yet continue to receive payments from the 
Federal Government. At that time, we committed to working with 
the IRS and CMS to find a solution. Since that time, much 
progress has been made toward implementing a pilot program to 
levy Medicare payments. Staffs from all three agencies 
participate in a subgroup of the Federal Contractor Tax 
Compliance Task Force formed to meet this challenge. FMS and 
CMS recently participated in a table-top exercise which walked 
through the proposed process for matching CMS payment records 
with records of delinquent taxpayers and levying those payments 
when appropriate.
    While the idea of collecting overdue taxes from Medicare 
providers is relatively straightforward, it is an enormously 
complex undertaking involving a significant number of systems 
and interfaces. Nevertheless, as a result of the commitment and 
dedication of the agencies and the support of this 
Subcommittee, the pilot program to levy Medicare payments is 
expected to begin in October 2008. In the interim, the task 
force is working to develop a manual process whereby FMS could 
provide information to IRS on specific Medicare providers who 
owe taxes so that IRS can issue paper levies. More detail 
regarding the accomplishments of the task force will be 
included in a written report to the Subcommittee early next 
year.\1\
---------------------------------------------------------------------------
    \1\ See Exhibit 2, which appears in the Appendix on page 105.
---------------------------------------------------------------------------
    You specifically asked me to address issues surrounding the 
levy of Medicaid payments in response to recent GAO findings on 
Medicaid providers who owe delinquent taxes. Unlike Medicare 
payments which are disbursed by the Federal Government, 
Medicaid payments to providers are issued by the States. This 
introduces additional legal and operational complexities not 
present under Medicare. The task force has already begun 
examining the issue of incorporating these payments into the 
levy program. Recently, the IRS has determined that such 
payments are not Federal payments subject to continuous levy 
under the current law. Nevertheless, FMS, along with IRS and 
CMS, will continue to examine the issue on how best to overcome 
existing legal hurdles and ensure that any process to levy 
payments is operationally feasible and not unduly burdensome 
and costly to the Federal Government or to the States. We 
expect this to be a complex and long-term effort. However, in 
the interim, because of the overlap between Medicare and 
Medicaid providers, we are optimistic that progress can be made 
toward reducing the tax obligations of Medicaid providers 
through our efforts to implement a process to levy Medicare 
payments next year.
    This concludes my statement. I would be happy to respond to 
any questions.
    Senator Levin [presiding]. Thank you, Mr. Papaj. Mr. Smith.

TESTIMONY OF DENNIS G. SMITH,\1\ DIRECTOR, CENTER FOR MEDICAID 
& STATE OPERATIONS, CENTERS FOR MEDICARE AND MEDICAID SERVICES, 
          U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

    Mr. Smith. Thank you, Mr. Chairman, Senator Coleman. It is 
a pleasure to be with you this afternoon to discuss Medicaid's 
relationship to the Federal Payment Levy Program. In fiscal 
year 2008, Medicaid will pay approximately $345 billion to 
hundreds of thousands of health care providers and plans 
including hospitals, nursing homes, physicians, and even 
taxicabs to provide health care services to about 50 million 
Americans. The Federal share of that amount is approximately 
$190 billion.
---------------------------------------------------------------------------
    \1\ The prepared statement of Mr. Smith appears in the Appendix on 
page 58.
---------------------------------------------------------------------------
    Medicaid is administered by the States, and many Medicaid 
providers contract directly with those States. The States are 
the ones who enroll the providers into the program. We, at the 
Federal level, in contrast to Medicare, in Medicaid we do not 
enroll providers, we do not pay providers directly. Our 
relationship is reimbursing the States. The States are the ones 
who undertake those administrative functions, and in terms of 
future discussions, I would suggest that we invite our 
partners, the States, to participate in any of the potential 
solutions that we might bring to bear.
    As stated previously, there has been work done in the most 
recent weeks prior to the hearing to examine the issue of 
whether or not Medicaid would qualify under the levy program. 
We do not believe that Medicaid does, that it does not qualify 
as a Federal payment. So I think there is the issue in the 
first place of the statutory limitations that we have.
    Obviously, we cannot prevent someone who has not lived up 
to their obligations under the law to pay their taxes. We 
cannot take action against someone that we do not know about, 
whether that is preventing them from enrolling in the program 
in the first place or by offsetting payments to them through 
the Medicaid program.
    There is a fair amount of overlap between Medicare and 
Medicaid, and oftentimes providers participate in both 
programs. But Medicaid in many respects goes well beyond the 
universe of Medicare. Medicaid reimburses for things that 
Medicare does not, very few other payers do not. Other payers 
generally are not paying taxicabs to help people with 
disabilities to get to their doctor's appointments, for 
example. We pay home and community-based services, oftentimes 
by community-based organizations, many of them governmental, 
many of them not-for-profit, and some for-profit. Some of those 
payers are not even--the payments are not made through the 
automatic claims processing system. So there would be 
significant funds that are disbursed by States to people who 
are not even paid through the automated system, so that would 
miss claims collections as well.
    And I think on the State side of things, having run a State 
Medicaid program and helped bring up a new MMIS system, States 
will rightfully ask if this is a responsibility outside the 
Medicaid program. States are rightly going to want to be paid 
fully for the cost of participating in that system.
    There are various capabilities across the States and 
territories in terms of their systems' capabilities. You have 
States in wide variation in terms of platforms that they are 
using. Some process in-house with State staff. Some are 
completely hired contractors, vendors such as EDS or ACS, who 
are running those systems on behalf of the States. So, again, 
there would be another level of--again, in terms of protecting 
taxpayer information, yet another level of involvement for 
people who actually run the systems on the States.
    And as I said, the States themselves are in various degrees 
of capacity. We have States that are bringing up new systems, 
States that are not fully integrated themselves, and States 
that run multiple systems. A large State like California, for 
example, is running multiple systems.
    So to bring all of those players into the fold would 
require, I think, significant resources to even start putting 
edits into a system, to systems that, as I understand, have 
been described to me as what Medicare is now doing on their 
side with the levy program, having that level of interface 
between these systems, it would not be unreasonable to estimate 
it would cost at least a couple of million dollars per State 
per system to be able to make those interfaces work.
    Let me conclude there, and I would be delighted to answer 
any questions.
    Senator Levin. Thank you, Mr. Smith. Thank you all.
    Let me start with you, Mr. Kutz, about how we would design 
a system where you could levy Medicaid payments. CMS, as 
everyone has stated, does not make direct payments to Medicaid 
service providers, does not keep track of who the providers 
are. So one possible first step would be to have CMS create a 
national registry of Medicaid service providers, requiring them 
to fill out an enrollment form similar to the ones that CMS now 
requires Medicare providers to complete. The form would have to 
ask providers for their taxpayer identification number, and for 
their consent to having CMS get tax debt information from the 
IRS. Is that accurate so far?
    Mr. Kutz. I believe so.
    Senator Levin. What would be, in your judgment, the cost 
and administrative burden involved in developing that form, 
creating a national registry, and keeping it updated?
    Mr. Kutz. I really cannot answer how much that would cost. 
Certainly it would take some time. One thing that is relevant 
to this also, the seven States that we looked at, which are 
five of the biggest--I think the five biggest, actually, along 
with two other ones that were near our headquarters and field 
offices, those States represented to us--and we did not audit 
this or investigate this--that they do have their own 
continuous levy programs over State payments for their own 
debts. So somehow tapping into that possibly is a way to do it 
for at least the bigger States. So I can speak to that. Again, 
we did not determine what that entails, but there seemed to be 
some promise in that.
    Senator Levin. All right. Well, let's go back to that, and 
then I will go to Mr. Smith and ask him what would be involved 
in having a new registry. On asking the States to do it on the 
ground that many of them now have a levy program for their own 
tax deficiencies, how many States, approximately, have some 
kind of a withholding system, a levy system on outgoing State 
funds to collect back State taxes? Do you know?
    Mr. Kutz. I can only speak to the seven. It was broader 
than taxes. It was any State debt. So they had it similar to 
the TOP program here in the Federal Government; it was broader 
than just State taxes.
    Senator Levin. Did you ask those States what would be 
involved if they broadened their program in order to collect 
Federal debt and presumably got some kind of a payment for 
doing that?
    Mr. Kutz. No, we did not.
    Senator Levin. Do you have an assessment as to how 
difficult it would be? Are you familiar enough with any of 
those States' collection systems?
    Mr. Kutz. No. We just wanted to see if it was feasible to 
operate a continuous levy program at that level by asking them. 
We did not go beyond to validate what they told us.
    Senator Levin. Which is that they have such a system.
    Mr. Kutz. They have them, yes. But we did not validate what 
the details were behind that or how difficult it would be. We 
wanted to see if it was feasible at that level, which obviously 
at the Federal level could be more complicated, but, again, at 
their level they were operating that.
    Senator Levin. And did you ask them at all their opinion 
about the practicality of collecting Federal taxes that were 
due?
    Mr. Kutz. I do not believe so.
    Senator Levin. So you have no idea of costs or 
complications. Do you know whether Congress would have to amend 
the law in order to allow States to get taxpayer information 
from the IRS or FMS, and then to screen and to levy the 
Medicaid payments?
    Mr. Kutz. Well, they could do it by getting a waiver of 
consent by the actual providers. So that is one way to do it 
without the change in the law; otherwise, you would potentially 
have to allow it by law.
    Senator Levin. All right. So we could ask them to collect 
these debts and then ask them to get waivers signed.
    Mr. Kutz. To check with IRS, yes, that is correct. If they 
signed a waiver as part of their enrollment or being in the 
program, they could actually do that, I believe.
    Senator Levin. Is it within your work orbit to check with 
those--was it seven States?
    Mr. Kutz. Seven States that represent 43 percent of 
Medicaid disbursements.
    Senator Levin. Would it be appropriate to ask you to check 
with those seven States----
    Mr. Kutz. We could certainly do that for you, yes.\1\
---------------------------------------------------------------------------
    \1\ See Exhibit 3, which appears in the Appendix on page 108.
---------------------------------------------------------------------------
    Senator Levin [continuing]. To see how much work it would 
be for them to go through that waiver process and then to 
collect and then to charge the Federal Government a portion of 
what they collect?
    Mr. Kutz. We could inquire on that, and certainly we could 
feed that into the task force, who is looking at the Federal 
level at the feasibility and see if there are any matches or 
anything that makes sense.
    Senator Levin. All right. If you would do that and let the 
Subcommittee know what the response was of the seven States.
    Now, let me go to you, Mr. Smith. What is your reaction to 
either that system, that possibility, or to create a national 
registry the way it apparently has been done for Medicare?
    Mr. Smith. Mr. Chairman, we have not looked at that as an 
issue. Clearly, there are hundreds of thousands of providers 
who participate in the Medicaid program. They also participate 
in ones that the individual who owes the tax liability is 
actually never identified because you might be an individual 
doctor working in a group practice, for example. So it is the 
group that is enrolled as the Medicaid provider, so you would 
not find the individual liability in that respect.
    Senator Levin. Is that true with Medicare as well?
    Mr. Smith. I believe that would be true as well, yes, sir.
    Senator Levin. Has that been a problem?
    Mr. Smith. I do not know to what extent they have 
encountered that issue.
    Senator Levin. How many Medicare providers are there? 
Medicare first, then Medicaid.
    Mr. Smith. Medicare, I do not--1 million Medicare 
providers. I believe there would be at least that many 
Medicaid, but although many of those would also overlap. A 
hospital, a nursing home, probably is participating in both. 
But as I said, there are also lots of Medicaid providers who 
are not Medicare providers, because we provide services beyond 
that.
    In terms of stopping someone from enrolling as a provider 
because they have a tax liability, clearly that would be one 
approach to it. Then, as I understand the levy program to work, 
you are withholding payment, as I understand it, up to 15 
percent of whatever payment. Payments to providers generally 
are made on a biweekly basis, so each State is running their 
claims as they are paying providers, so every time you are 
paying, you are also making an adjustment in reducing the 
amount of money that provider is due.
    That is done on an ongoing basis, so that would be more 
than just the one time stopping you from enrolling because you 
have a tax liability.
    Senator Levin. Is there a form right now that Medicaid 
requires providers to fill out?
    Mr. Smith. Yes, sir. States requires providers to--when 
they do enroll their providers, they do various levels of 
qualifying, credentialing, professional licenses, as well as 
the tax identification, etc.
    Senator Levin. Is that a Federal form or a State form?
    Mr. Smith. States would have their own forms of how they 
enroll them, and, again, because each State runs their own 
management information system, it is going to be unique to have 
that system be able to take in that type of information and 
have it automated.
    Senator Levin. And that form, is that made available to the 
Federal Government?
    Mr. Smith. We certainly could ask the States for it.
    Senator Levin. But you do not get them routinely?
    Mr. Smith. Not routinely, as I said, because the States are 
actually doing the enrollment.
    Senator Levin. Well, they do the enrollment, but is there 
any information from those forms that you routinely obtain?
    Mr. Smith. Not on a routine basis.
    Senator Levin. Survey information or other information?
    Mr. Smith. We could collect that, Mr. Chairman, but 
routinely it would not come to us.
    Senator Levin. And can you tell this Subcommittee for the 
record how large a problem you think it would be for you to ask 
the States to obtain waivers for you?
    Mr. Smith. Again, I think the States would be asking for 
the waiver from the individual. It is the provider who has to 
waive their right for them to be able to have that information.
    Senator Levin. Can you, for the record, tell this 
Subcommittee how difficult it would be for you to ask all the 
States in their forms, for the taxpayer information and to tell 
Medicaid providers that by participating in the program they 
are waiving their right to have that information withheld from 
you folks? Will you tell us for the record? Unless you can tell 
us right now. Does that sound like a big deal to you?
    Mr. Smith. I do not think it is. We certainly can ask the 
States to do that, if I understand that is what the request is.
    Senator Levin. You do not think that would be a big deal?
    Mr. Smith. We could do that.
    Senator Levin. OK. Thank you. Senator Coleman.
    Senator Coleman. Thank you, Mr. Chairman.
    First, I do want to express my appreciation for the 
progress that has been made in Medicare, and my sense is that 
presented a number of complexities. Mr. Papaj, in your 
testimony you talk about a one-day test match with CMS, 
matching Medicare Parts A and B payments with the Healthcare 
Integrated General Ledger Accountant System, HIGLAS, and you 
indicate in your testimony just with one day with the tax debts 
and the Federal Payment Levy Program, when activated for a 
levy, it resulted in 335 matches with potential collections of 
$1.1 million. So there is work being done, and you are making 
progress working with CMS and IRS to say we could be collecting 
money in the Medicare program. And I think it is fair to say it 
is a complicated program. You would not disagree with that 
assessment?
    Mr. Papaj. No. Medicaid is certainly more complicated than 
the Medicare program.
    Senator Coleman. In regard to Medicaid, what we are talking 
about here is the continuous levy, and so one of the technical 
problems, Mr. Smith, as has been indicated, is that States do 
not qualify as--they are not agents of the Federal Government 
by the nature of being a State. Is that what the legal bar is, 
that we are dealing with States that are not agents of the 
Federal Government? Is that why we cannot--I am not talking 
about the technical side, just the legal side. Is that the 
barrier there? Ms. Stiff.
    Ms. Stiff. Yes, our legal counsel has looked at what would 
constitute a Federal payment, and in a nutshell, there are 
three factors that are contributing to the analysis that these 
do not qualify as legal payments. The first is the flow of 
funds, meaning that the States are actually making the payments 
to the providers. Second, the relationship between the State 
and the providers, and the States actually establish the 
criteria and the thresholds for eligibility to participate. 
They render the decisions on whether the claims are to be 
allowed or disallowed. Third, in the event of a dispute over 
the payment or the non-payment by the provider, the State is 
the responsible party, not the Federal Government.
    Senator Coleman. Correct me if I am wrong, but the IRS can 
currently levy Medicaid payments. Is that correct, through a 
paper levy?
    Ms. Stiff. Yes, we do it through the paper levy, which is a 
little bit different process.
    Senator Coleman. But you can levy Medicaid payments.
    Ms. Stiff. Yes, we can.
    Senator Coleman. Payments made by the State, but the 
difference is a paper levy.
    Ms. Stiff. The paper levy process allows us to levy what is 
before us today. It does not call for the continuous levy 
against the next payment and the next payment to capture the 
full amount.
    Senator Coleman. So the levies are essentially--what is 
it--a 30-day levy?
    Ms. Stiff. One day.
    Senator Coleman. Hypothetically, could it be a 60-day levy? 
Could it be 90 days?
    Ms. Stiff. We would need to review that and see if we need 
a statutory, regulatory, or procedural change on that.
    Senator Coleman. Do you have any objection from the States 
in terms of using the paper levy? Does that create any problems 
in terms of the relationship with the States?
    Ms. Stiff. No. I think the issue that constraints the paper 
levy is the fact that it is a one-time event as opposed to 
getting every payment that comes their way in the future.
    Senator Coleman. And, again, I am just going to----
    Ms. Stiff. We will look at that.
    Senator Coleman. We can levy payments, so the issue really 
is using a Federal program that would provide for a continuous 
levy, again, understanding that there are significant hurdles. 
My concern is that we know there are hurdles. We know there are 
hurdles with Medicare where folks got together, with some 
resistance. Mr. Smith, I know you were not part of it, I do not 
believe, personally involved in the Medicare trouble. I think 
you are a Medicaid person, right? You are not a Medicare 
person.
    Mr. Smith. Correct. I am Medicaid.
    Senator Coleman. But, Mr. Kutz, I will turn to you. Is it 
fair to say that we had difficulty with CMS in terms of getting 
information and getting it when it was requested?
    Mr. Kutz. Yes, I would say that.
    Senator Coleman. And so what I am looking for is 
recognizing the challenges but understanding that, in fact, we 
do levy payments, that we can do it in a micro sense. I would 
hope that we would pull together--by the way, Mr. Smith, you 
made a good recommendation. Bring the States into the 
discussion. I think they should be part of the solution.
    But, clearly, paper levies are not, Ms. Stiff, the most 
effective way to collect unpaid taxes. Is that a fair 
statement?
    Ms. Stiff. Well, they are not ineffective. It is just that 
when you have this recurring income stream, the paper levy 
constrains your ability to capture against the future earnings.
    Senator Coleman. Mr. Kutz, if I can, just in terms of the 
size of the problem, you have looked at seven States, and that 
constituted what percentage of the total of Medicaid payments?
    Mr. Kutz. Forty-three percent, Senator.
    Senator Coleman. Maybe it is too simplistic to say a 
doubling, but we looked at less than half of the transactions 
that are being conducted with Medicaid. Is that correct?
    Mr. Kutz. Correct.
    Senator Coleman. And as Mr. Smith indicated, there is some 
overlap even of the cases that you looked at?
    Mr. Kutz. There were 2,000 cases that we discussed in March 
of Medicare physicians and other suppliers that were in our 
30,000 for today's study.
    Senator Coleman. In your testimony you talked about the 
range of other problems that the individuals who were 
scofflaws, who were tax deadbeats, and you kind of went through 
a litany. I am trying to figure out would it be fair to say 
that a failure to pay tax debt could be a marker in terms of 
health care providers who have other problems or, perhaps even 
more importantly, are not providing quality health services? 
Did you see a correlation there?
    Mr. Kutz. Again, we did not do a statistical sample, a 
broad study, but certainly our work overall has shown that 
people who are tax fraudsters for decades, that is not the only 
issue they have got. And with respect to the Medicare cases we 
did in March and the ones for Medicaid today, they did have an 
unusually high preponderance of other criminal activity, health 
care violations, suspicious activity reports, strange cash 
transactions going on. So these are--at least the egregious 
cases--professional fraud cases.
    Senator Coleman. And would it be fair to say that we saw 
the same patterns when we looked at defense and civilian 
contractors who were not paying their taxes, when we looked at 
GSA contractors who were not paying taxes, and when we looked 
at Medicare? In all your investigations we have been involved 
in, at least my recollection is that we have found similar 
patterns. Is that a fair statement?
    Mr. Kutz. There are hundreds of cases in the similar 
patterns, yes.
    Senator Coleman. One of the concerns, Mr. Smith--and I want 
to make sure that we are not undermining the ability to provide 
service. The nice thing about a levy system is keeping folks 
providing service. You are just making sure that as we are 
paying them, we are holding back a percentage of that payment 
so that they are paying their obligations. And I am not sure 
how you do this, but I would hope that you would be screening 
or looking at the issue of quality service. Is that fair, that 
CMS does look at the quality of service?
    Mr. Smith. Certainly, Senator, and we have under my Center, 
we have the survey and certification responsibility also. So if 
there is a quality-of-care issue in a nursing home or a 
hospital and the GAO has referrals to us, we absolutely have 
other ways to deal with people who are endangering the lives 
and health of the people that we serve.
    Senator Coleman. And then just a last question----
    Mr. Kutz. Senator, could I mention one thing?
    Senator Coleman. Yes, Mr. Kutz.
    Mr. Kutz. One of the problems we have is we cannot refer 
these cases to CMS. We can only refer them to IRS, and that 
gets into the law on the sharing of tax information, 6103. So 
that is an important point here. We would love to be able to 
share these 25 cases with CMS, but we cannot by law.
    Senator Coleman. One of the things, Mr. Chairman, that I am 
going to ask the entire panel to do is to go back and to look 
at the existing system and to spend a little time, identify the 
challenges and the bars to effectively utilizing the Federal 
payment levy system in dealing with Medicaid, if there are 
issues with the States, issues with funding. Mr. Smith, you 
have indicated it may cost $100 million. We are talking about 
half the cases returning $160 million in 1 year. That may be 1 
year's cost, if it is the cost. But my request to this panel is 
for FMS and CMS and IRS to go back and put your heads together, 
and for GAO to be involved in that discussion, and let us know 
what is it that we have to do on the legal side, on the 
definition of what a Federal entity is, etc., and in a way that 
makes sense, makes good common sense. I think if you do that, 
it would be a tremendous service, and it would be a service to 
all the taxpayers of this Nation.
    Thank you, Mr. Chairman.
    Senator Levin. Thank you, Senator Coleman.
    Let me make that request in another way. I think it is the 
same request, essentially, but basically, each of you, what 
would you recommend--first your top recommendation, second 
recommendation, third recommendation--to increase Federal tax 
levy collections? I think that is what Senator Coleman's 
question is. If you want to get together and make those 
recommendations jointly, fine. But I would say that within 30 
days we would like those recommendations. Can each of you give 
us recommendations of that kind within 30 days? Mr. Kutz.
    Mr. Kutz. Yes.\1\
---------------------------------------------------------------------------
    \1\ See Exhibit 3, which appears in the Appendix on page 108.
---------------------------------------------------------------------------
    Senator Levin. Ms. Stiff.
    Ms. Stiff. Yes.\2\
---------------------------------------------------------------------------
    \2\ See Exhibit 2, which appears in the Appendix on page 105.
---------------------------------------------------------------------------
    Senator Levin. OK. Mr. Papaj.
    Mr. Papaj. We will try to do so.\2\
    Mr. Smith. I would be happy to, Mr. Chairman.
    Senator Levin. OK. Thank you.
    We have a vote on now, which I think we have about 6 
minutes left to make any comments. I would just ask a couple 
questions here, and we will recess.
    Do you have additional questions?
    Senator Coleman. I will go vote and then come back.
    Senator Levin. So we will put this hearing in recess for 
your additional questions. OK. I just have a couple additional 
questions, and then I will leave.
    This, I think, is for you, Mr. Smith. Is there a standard, 
a rule, a procedure that you have that says that medical 
service providers who have outstanding tax debts are ineligible 
to participate in the Medicaid program?
    Mr. Smith. I do not believe there is such a thing, and, 
again, Mr. Chairman, the issue for us is we do not know who has 
a tax----
    Senator Levin. No, I understand that. What I am asking is 
that if you have a standard which says that if you have a tax 
debt, you are ineligible to participate? You may not know who 
is lying to you, but on your application or your provider's 
form, you would have a statement, ``the undersigned has no 
outstanding tax debt.'' I am not saying you would know who is 
lying, but it would be a false statement to a Federal agency 
for them to say they do not have a tax debt if they do. And 
there would be some people who might be reluctant to lie to a 
Federal agency in order to participate in the program, since 
that is illegal.
    Mr. Smith. Again, Mr. Chairman, the States are the ones who 
would be enrolling the providers, so they would not be making a 
statement to a Federal official.
    Senator Levin. Fair enough. Do any of the States, do you 
know, have that statement that they ask their providers to 
make?
    Mr. Smith. I am not aware, Mr. Chairman, but there very 
well may be. I would have to check. I do not believe we had 
such a provision in Virginia when I ran Virginia Medicaid.
    Mr. Kutz. Mr. Chairman, I understand, my staff has told me, 
that California may have such a provision, and we could 
certainly----
    Senator Levin. Could you check that out?
    Mr. Kutz [continuing]. Check that out for you, yes.
    Senator Levin. Would you have any problem, Mr. Smith, or 
would your agency have any problem requiring States to add a 
representation on the application of the provider that the 
provider has no outstanding Federal tax debt?
    Mr. Smith. Mr. Chairman, I would have to talk with counsel 
to see if that would be allowable. The Medicaid statute itself 
has certain provisions, and if we could require it--I would not 
have any problem with requiring it if we have the authority.
    Senator Levin. Would you let us know if you have any 
problem with that?
    Mr. Smith. I would be happy to, Mr. Chairman.\1\
---------------------------------------------------------------------------
    \1\ See Exhibit 4, which appears in the Appendix on page 115.
---------------------------------------------------------------------------
    Senator Levin. All right. There was some discussion here, 
Ms. Stiff, about the paper levies. Can you change the 
expiration date on the paper levies--is that doable--without 
changing law or regulation?
    Ms. Stiff. I do not know. I am going to have to go back and 
verify that.
    Senator Levin. Would you let us know about that as well?
    Ms. Stiff. I will.
    Senator Levin. OK. We are going to stand in recess until 
one or more of my colleagues comes back. I am not going to be 
able to come back, so let me thank you for your testimony.
    We will stand in recess probably for no more than 5 
minutes, but until a Senator comes and picks up this gavel, we 
are in recess.
    [Recess.]
    Senator Coleman [presiding]. This hearing is reconvened. I 
have a few more follow-up questions.
    Mr. Papaj, as I was looking at the charts of collections, 
it appears that collections declined for 2007, declined from 
$59.6 million in 2006 to $47.4 million in 2007. Can you help me 
understand the reason for the decline?
    Mr. Papaj. I think the key point is even though the dollar 
amounts went down, the number of levies that----
    Senator Coleman. And these are contractor collections, 
right?
    Mr. Papaj. Right. The number of payments that we received 
for the levy actually increased 11 percent, and we cannot 
control the dollar amount of the payments. But what I think is 
important is that we continue to get the stream of payments 
that we can do the levies on, and that continues to show an 
increase.
    Senator Coleman. And I am wondering--and I would turn to 
Ms. Stiff--do we have any sense that Federal contractors are 
settling up with the IRS? In other words, they know the system 
is in place and----
    Ms. Stiff. Yes, sir.
    Senator Coleman. Is there some sense that is happening, Ms. 
Stiff?
    Ms. Stiff. Yes, sir, on two fronts. Let me add on to what 
Mr. Papaj just said.
    On the decline from almost $56 million down to the $48 
million, I think there are two factors contributing to that. 
One was that in the prior year there were several large 
payments that were kind of anomalies and are not repeating 
themselves as opposed to an actual decline.
    Senator Coleman. A $6 million payment by one DOD contractor 
in 2006. Is that correct?
    Ms. Stiff. Yes, sir. And I think those anomalies are 
contributing to that decrease.
    Senator Coleman. Are folks settling up? Is there a sense--
--
    Ms. Stiff. Yes, sir.
    Senator Coleman [continuing]. That you are seeing more 
settling up with kind of the entire debt rather than getting 
involved where you are going to have some levy imposed against 
you and whatever stigma attaches with that?
    Ms. Stiff. We implemented the FPLP program in fiscal year 
2000, and I believe that we reported to you today that we have 
collected a little over $1 billion through that process. It is 
interesting to note that we send a Notice of Intent to Levy to 
taxpayers that go into this program on the front end. Since 
that same time frame, we have collected just under $1 million 
from taxpayers who did exactly what you are talking about, 
which is to settle up as a result of the Notice of Intent to 
Levy.
    Senator Coleman. And one of the reasons I raise the 
question, it goes to the request from the Chairman and the 
request that I offered for folks here to come back with--to 
figure out a way for us to do it. There is no question but that 
there is money out there. Some folks, if you put the system in 
place or give people the opportunity to settle up, we are going 
to benefit. There are going to be more dollars coming in that 
people owe. We are not taking cash out of their pockets that 
they do not owe. They have obligations here that they have not 
lived up to.
    Let me ask a question about criminal prosecution. There is 
no question IRS has aggressively pursued tax cheats from a 
collection standpoint. Can you talk to me a little bit, Ms. 
Stiff, about the philosophy involved in criminal prosecution? 
And the question is raised--and perhaps it was Mr. Kutz in some 
of our conversations. You have referred, what, 122 cases to the 
IRS? Is that a correct number?
    Mr. Kutz. No. If you count all of the different tax-related 
ones we have done, it is probably 250 or 300.
    Senator Coleman. And how many of those have been followed 
up with criminal prosecution, do you know?
    Mr. Kutz. I think the IRS would have to answer. I am not 
aware of any prosecutions related to those referrals.
    Senator Coleman. Ms. Stiff.
    Ms. Stiff. We have established a special process to deal 
with all the referrals that have come from GAO over the course 
of the hearings and their investigations on the FPLP program. 
Each and every one of those cases has been reviewed or is being 
reviewed, in some instances by our Criminal Investigative 
Division. A full review of the facts, the circumstances, and 
analysis to determine if criminal prosecutions are merited--I 
can get you the numbers for the record. I do not have the exact 
number. I do not know the number off the top of my head. 
Probably fewer than a dozen that have actually been followed 
through on.
    Senator Coleman. Is there a line that is drawn or can you 
help me understand some of the factors that go into determining 
whether something moves from being a civil collection, an 
outlandish abuse of failing to pay obligations? At what point 
does it kind of move into the criminal realm?
    Ms. Stiff. Well, I think as we all know, the bar for 
criminal prosecution is set much higher. Certainly before 
someone wants to take a case into court, it needs to have some 
jury appeal; given the facts and circumstances, they need to 
believe they have a case they can win.
    In many of these cases, we have instances where taxpayers 
have subsequently gone out of business. We have many instances 
where they have subsequently gone bankrupt. We have many 
instances where they actually make payments sporadically and 
then do not, which would cause a jury in a court proceeding to 
determine that those were actually bad business decisions as 
opposed to a matter of criminal intent.
    So there are a number of factors when you actually get 
behind some of these cases that make it difficult to sustain 
criminal indictment and prosecution.
    Senator Coleman. I understand, Mr. Papaj, that you are 
going to be retiring.
    Mr. Papaj. Yes, Senator.
    Senator Coleman. I will take this opportunity on the record 
to thank you for your efforts. I think we have made tremendous 
progress in this area from when we first started, and we 
understand the complicated nature of what we are trying to 
accomplish. But the benefit for the taxpayer is just so 
enormous, there is a mother lode of dollars out there where the 
obligation is clear, is absolutely clear, and the ability to 
collect is at hand because we are still paying these folks. So 
this is not a cash flow issue. This is not somebody who cannot 
afford to pay. We are paying them at a time that they have 
obligations, significant obligations.
    So the challenge we have is to put in place a system 
whereby we could use something like the levy process, and I 
just want to express my appreciation for your service and 
working in partnership with the other agencies and figuring out 
a better way to do this. I was looking at some of the numbers. 
DOD, from where we started, I think $700,000 with Federal 
defense contractors collected in the levy system, and in fiscal 
year 2006, I think it is about $31 million. That is over a 
4,000-percent increase, I think systemwide, with some figures 
that have shown over an 800-percent increase in collections.
    So what we can do is we can set it up, and with the work of 
Mr. Kutz and his associates at GAO, but ultimately folks have 
to work the system. I will end on this note.
    But, again, Mr. Smith, you were not involved in Medicare. 
That was complicated, and there is a sense from this Senator's 
perspective that we did not get the kind of response from CMS 
originally that we are going to work and we are going to figure 
this out. It just seemed like we were pulling teeth.
    I will tell one quick story. Thomas Jefferson, the Virginia 
countryside during the time when he was President, he was with 
a bunch of other friends traveling on horseback, and they came 
to a portion of a river where there is no bridge, and so they 
cannot go across a bridge. They have to wade across. And as 
they are wading across, one by one the party goes across. The 
President is the last guy to go, and there is a guy standing on 
the side there with a big bundle of goods. And everyone 
proceeds. The last guy left is the President. As he is about to 
get on his horse, the guy goes up to the President and says, 
``Excuse me. Can you help me get across?'' And Jefferson says, 
``Absolutely.'' And he kind of repositions himself, and they 
get across the river. And when they come to the other side, one 
of the guys in Jefferson's party goes, ``The President says''--
he goes up to this guy, and he is outraged at this guy. And he 
says, ``Who do you think you are? That was the President of the 
United States and you asked him to carry you across the river? 
You could have asked any one of us, but you asked the 
President.'' And the guy's response was, ``Well, I am sorry. I 
did not know who he was. But I looked at all your faces, and 
they said no. And I looked at his face, and it said yes.''
    And what I am looking for is a face that says yes. In spite 
of all the challenges and the complexities, if we say we can 
figure out a way to do this without undermining the system, 
without limiting or lessening the quality of care, without 
burdening States--and I am a former mayor, a local elected 
official. I am deeply concerned about unfunded mandates. But I 
really think we have within ourselves the capacity to say yes 
and to figure this out. We have come a long way, and we will 
continue marching down this path. But we need everyone's 
cooperation.
    So I look forward to that cooperation. I appreciate the 
good work that CMS does. I recognize the challenge they have.
    Mr. Papaj, we will continue on without you, but hopefully 
your successor will carry your face that says yes into the fray 
and into the conversation.
    Mr. Papaj. Thank you, Senator, and thanks for the support 
of the Subcommittee and the staff. It has been a great run, and 
I think what we need is to work together to be innovative, to 
be creative, and to try to find solutions.
    Senator Coleman. Thank you.
    With that, this hearing is adjourned. I will for the record 
note that we will keep the record open for 2 weeks, plus we 
expect to have a report back from the witnesses within 30 days.
    [Whereupon, at 5:18 p.m., the Subcommittee was adjourned.]
                            A P P E N D I X

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