Post on 16-Dec-2015
National Fraud Prevention Program:
Analytics in Medicare and Medicaid
National Fraud Prevention Program:
Analytics in Medicare and Medicaid
Center for Program IntegrityCenters for Medicare & Medicaid ServicesDepartment of Health & Human Services
March 15, 2012
INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAWThis 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.
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CPI’s Strategic DirectionCPI’s Strategic Direction
Established Approach New Approach
5 Government Centric
1 Pay and Chase
2 ‘One Size Fits All’
3 Legacy Processes
4Inward Focused Communications
Engaged Public & Private Partners
Prevention and Detection
Risk-Based Approach
Innovation
Transparent and Accountable
Coordinated & Integrated PI Programs6
Stand Alone PI Programs
The New Approach to Combating Fraud, Waste, and
Abuse
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
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National Fraud Prevention Program
Two Concurrent Approaches
National Fraud Prevention Program
Two Concurrent Approaches
Provider Screening(Enrollment
)
Predictive Analytics(Claims)
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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
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Presentation AgendaPresentation Agenda
Medicare Predictive Analytics
Fraud Prevention System (FPS)
Provider EnrollmentAutomated Provider Screening
(APS)
Medicaid
Fraud Prevention System (FPS)Fraud Prevention System (FPS)
• Implemented on June 30, 2011.
• 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.
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The FPS Scores Claims Prepayment
The FPS Scores Claims Prepayment
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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
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3
2
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1Claim
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4
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Automated Provider Screening (APS)
Automated Provider Screening (APS)
• CMS implemented the Automated Provider Screening (APS) system on December 31, 2011.
• 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
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Other Key FactsOther 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.
Provider Screening Systems Integration
Provider Screening Systems Integration
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Medicare Administrative
Contractors
Pay.gov National SiteVerificationContractor
PECOSApp
APS
Analytics Lab | Command Center |Provider Screening Lab
CMS AnalyticsFPSFuture models
Denied
Approved
PTAN
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Presentation AgendaPresentation Agenda
MedicareMedicaid
Overview: Status and Goals
State & Federal Programs Medi-Medi MACBIS MII
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Medicaid ContextMedicaid 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
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Differences Between Medicaid & Medicare
Differences Between Medicaid & Medicare
Medicaid Medicare
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
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Dual EligibleDual 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
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Primary GoalsPrimary 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
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State-Federal ProgramsState-Federal Programs
• Medi-Medi Data Match Project
• Medicaid and CHIP Business Information and Solutions (MACBIS)
• Medicaid Integrity Institute (MII)
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Medicare/Medicaid Data Match Project (Medi-Medi)
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
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Medicaid and CHIP Business Information and Solutions (MACBIS)
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
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Medicaid Integrity Institute (MII)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
National Fraud Prevention Program
Two Concurrent Approaches
National Fraud Prevention Program
Two Concurrent Approaches
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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)
MedicaidMedicareProgramIntegrity