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National Fraud Prevention Program: Analytics in Medicare and Medicaid Center for Program Integrity Centers for Medicare & Medicaid Services Department.

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Presentation on theme: "National Fraud Prevention Program: Analytics in Medicare and Medicaid Center for Program Integrity Centers for Medicare & Medicaid Services Department."— Presentation transcript:

1 National Fraud Prevention Program: Analytics in Medicare and Medicaid Center for Program Integrity Centers for Medicare & Medicaid Services Department of Health & Human Services March 15, 2012 INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the fullest extent of the law.

2 CPI’s Strategic Direction Established Approach New Approach 5 5 Government Centric 1 1 Pay and Chase 2 2 ‘One Size Fits All’ 3 3 Legacy Processes 4 4 Inward Focused Communications Engaged Public & Private Partners Prevention and Detection Risk-Based Approach Innovation Transparent and Accountable Coordinated & Integrated PI Programs 6 6 Stand Alone PI Programs 2

3 The New Approach to Combating Fraud, Waste, and Abuse Yesterday Providers suspected of fraudulent activity are put on prepay review, sometimes indefinitely CMS initiates overpayment recovery Law enforcement determines if an arrest is appropriate Today & Future State CMS will deny individual claims CMS and its contractors will use prepay review as an investigative technique CMS will revoke providers for improper practices CMS and Law Enforcement collaborate before, during and after case development CMS will address the root cause of identified vulnerabilities 3

4 National Fraud Prevention Program Two Concurrent Approaches Provider Screening (Enrollment) Predictive Analytics (Claims) 4 Identify bad actors and prevent them from enrolling Take quick action to remove bad actors Identify & prevent improper payments Take quick action to remove bad actors

5 Presentation Agenda  Medicare  Predictive Analytics Fraud Prevention System (FPS)  Provider Enrollment Automated Provider Screening (APS)  Medicaid 5

6 Fraud Prevention System (FPS) Implemented on June 30, Monitors 4.5 million claims (all Part A, B, DME) each day using a variety of analytic models. Alerts generated and consolidated around providers and subsequently prioritized based on risk. Results are provided to the Zone Program Integrity Contractor analysts and investigators with views by regions. Results are available to CPI and law enforcement partners in a prioritized national view. 6

7 The FPS Scores Claims Prepayment 7 Fraud Prevention System Medicare Administrative Contractors (Shared Systems) CMS Common Working File (Consolidated Data) Payment Floor Center for Program Integrity Law Enforcement Zone Program Integrity Contractors CMS Command Center Claim 4

8 Automated Provider Screening (APS) CMS implemented the Automated Provider Screening (APS) system on December 31, The APS: –Validates data received from providers on enrollment applications against referential data –Identifies applications of providers that may be high risk based on specific indicators –Assigns a risk score to each provider 8

9 Other Key Facts Increased Data Sources –APS leverages thousands of government, public, and private resources to verify and supplement data submitted by providers. Monitoring Alerts –APS monitors critical eligibility requirements (e.g. sanctions, death, convictions) and immediately alert CMS to any changes. –APS also regularly re-screen all information on a provider enrollment application for continued accuracy. Unified Screening Process –APS will provide a unified screening process for all MACs to ensure that all Medicare providers are screened with the same degree of rigor. 9

10 Provider Screening Systems Integration 10 Medicare Administrative Contractors Pay.gov National Site Verification Contractor PECOS App APS Analytics Lab |Command Center |Provider Screening Lab CMS Analytics FPS Future models Denied Approved PTAN

11 Presentation Agenda  Medicare  Medicaid  Overview: Status and Goals  State & Federal Programs  Medi-Medi  MACBIS  MII 11

12 Medicaid Context Medicaid is a joint Federal and State Health Care Program providing coverage to over 56 million eligible low-income people. Program is administered by the State and have considerable flexibility in how they administer their Medicaid Programs and operate their Medicaid Management Information System Programs have independent provider identification methods, making national identity matching difficult 12

13 Differences Between Medicaid & Medicare MedicaidMedicare Relationship to Provider Federal relationship is with State State has relationship with provider Direct relationship to provider Data Sources CMS relies on States to provide Medicaid claims data CMS contractors supply Medicare claims data. Overpayment Recovery CMS collects the overpayment (Federal share) from the State, the State must collect from provider. CMS collects overpayments directly from Medicare provider. Appeals Two systems of appeal: Provider appeals to State State appeals to CMS One appeal system 13

14 Dual Eligible Dually eligible individuals make up 19% of Medicare beneficiaries and account for 40% of all Medicare and Medicaid costs 80% of the estimated $319.5 billion spent on dual eligibles is federal funding 14

15 Primary Goals Medicaid Predictive Analytics: April 2015 CPI and the Center for Medicaid & CHIP Services are partnering now to lay the foundation for predictive analytics: Ensuring accurate claim and payment data Enabling timely data feeds and updates Standardizing data formatting Developing comprehensive provider profiles 15

16 State-Federal Programs Medi-Medi Data Match Project Medicaid and CHIP Business Information and Solutions (MACBIS) Medicaid Integrity Institute (MII) 16

17 Medicare/Medicaid Data Match Project (Medi-Medi) Purpose Transition toward prevention and quick administrative action to prevent losses Identify program vulnerabilities related to beneficiaries and providers in both programs Integrate Medicaid and Medicare data to conduct national data matching and analysis 17

18 Medicaid and CHIP Business Information and Solutions (MACBIS) Purpose Develop IT tools to allow access to State Medicaid information Integrate program and operational data Implement health and cost metrics Increase operational efficiency Reduce burden on States 18

19 Medicaid Integrity Institute (MII) CMS is incorporating predictive analytics into its State-oriented curriculum: –Sharing knowledge of experts in managed care and fee-for-service data –Instruction in data collaboration and investigation –Sharing lessons learned from implementing predictive analytics in Medicare 19

20 National Fraud Prevention Program Two Concurrent Approaches 20 Identify bad actors and prevent them from enrolling Take quick action to remove bad actors Identify & prevent improper payments Take quick action to remove bad actors Provider Screening (Enrollment) Predictive Analytics (Claims) MedicaidMedicare


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