Presentation on theme: "Click to edit Master title style Program Integrity: Fraud & Abuse Glendon Schuster Senior Vice President and Chief Technology Officer Alliance for Health."— Presentation transcript:
Click to edit Master title style Program Integrity: Fraud & Abuse Glendon Schuster Senior Vice President and Chief Technology Officer Alliance for Health Reform Panel Briefing March 5, 2012
It is the policy of Centene Corporation to conduct its business affairs in accordance with the standards and rules of ethical business conduct and to abide by all applicable laws, both in letter and spirit. In this, there is no compromise. - Michael F. Neidorff Chairman, President and CEO
Program Integrity at Centene Conventional Methods Preventive Approach Supporting Program Integrity
Program Integrity – Conventional Methods 4 Prepayment Reviews – Billing Patterns System Edits Strategic Partnerships Post Payment Investigations Data Mining Provider Profiling Referrals Member Reviews Data Mining Service Validation Centelligence Through Centelligence we take our conventional methods of Program Integrity to the next level.
Centene Preventive Approach Demand for faster, more accurate payment provides opportunities for engagement. Health Information Technology Provider Partnerships Coordinated Care Collaboration with our State Partners
Health Information Technology (HIT) –Administrative Efficiency / Electronic Data Interchange (EDI) –Electronic Health Records, Member Health Records, Personal Health Records, Health Information Exchange Provider Partnerships –Provider Support – Electronic Claim Submission –Joint Venture Partnerships Care Coordination –Member Connections –Co-Location Provider Offices and FQHC –Case Management State Partnerships –Participate with other MCOs and State If you can run the company a bit more collaboratively, you get a better result, because you have more bandwidth and checking and balancing going on. Larry Page, co-founder of Google Centene Preventive Approach
Program Integrity - Results Centelligence Stopping Shopping for Narcotics System edits decreased trends in doctor shopping trends for this group of patients at 6 months: 95% decrease in South Carolina 80% decrease in Ohio 90% decrease in Florida 98% decrease in Georgia EMPLOYEE EDUCATION An employee reported concerns that a home health agency may have been billing for services that the Foster Parent was providing to their Foster Child. A record review validated the allegation and identified a potential overpayment of $1.3 million. The provider was reported to OIG for potential fraud. We identified an Ophthalmologist consistently billing procedures on five consecutive days to enrollees that lived in the same apartment complex. Review of the records indicated significant concern and the case was referred to the MFCU.