For Limited DistributionThe following disclaimer applies: Regarding all Healthcare Fraud Prevention Partnership communications and activities, this is a purely voluntary activity.  The committees

regarding data sharing and analysis;  information sharing; and the Executive Board, are to be used solely as discussion groups where the individual members can share facts or information or individual input.  No group or consensus advice or recommendations will be given by the partners in the committees or the Executive Board.  In addition, no policy-making or decision-making will be performed by the committees or the Executive Board.  The Secretary and the Attorney General or their designees will make the final policies or

other decisions.

HEALTHCARE FRAUD PREVENTION PARTNERSHIP(HFPP) Overview

June, 2013

For Limited Distribution

The following disclaimer applies: Regarding all Healthcare Fraud Prevention Partnership communications and activities, this is a purely voluntary activity.  The committees regarding data sharing and analysis;  information sharing; and the Executive Board, are to be used solely as discussion groups where the individual members can share facts or information or individual input.  No group or consensus advice or recommendations will be given by the partners in the committees or the Executive Board.  In addition, no policy-making or decision-making will be performed by the committees or the Executive Board.  The

Secretary and the Attorney General or their designees will make the final policies or other decisions.

ENDLESS OPPORTUNITIES…..

HFPP

Claims

Compromised Patient Data

Fraudulent Providers

Par

tner

#Z

Partner #X

Partner #Y

Enhanced

Fraud-

Fighting

Capabilities

For Limited Distribution

The following disclaimer applies: Regarding all Healthcare Fraud Prevention Partnership communications and activities, this is a purely voluntary activity.  The committees regarding data sharing and analysis;  information sharing; and the Executive Board, are to be used solely as discussion groups where the individual members can share facts or information or individual input.  No group or consensus advice or recommendations will be given by the partners in the committees or the Executive Board.  In addition, no policy-making or decision-making will be performed by the committees or the Executive Board.  The

Secretary and the Attorney General or their designees will make the final policies or other decisions.

PURPOSE OF THE HEALTHCARE FRAUD PREVENTION PARTNERSHIP (HFPP)

• To exchange facts and information between the public and private sectors in order to reduce the prevalence of health care fraud

• To enable members to individually share successful anti-fraud practices and effective methodologies and strategies for detecting and preventing health care fraud

• To focus on information sharing in two primary areas:• Data sharing and analytics• Outreach, education and information sharing

For Limited Distribution

The following disclaimer applies: Regarding all Healthcare Fraud Prevention Partnership communications and activities, this is a purely voluntary activity.  The committees regarding data sharing and analysis;  information sharing; and the Executive Board, are to be used solely as discussion groups where the individual members can share facts or information or individual input.  No group or consensus advice or recommendations will be given by the partners in the committees or the Executive Board.  In addition, no policy-making or decision-making will be performed by the committees or the Executive Board.  The

Secretary and the Attorney General or their designees will make the final policies or other decisions.

PROGRESS TO DATE

• Officially established by a Charter in fall 2012• Signed by HHS Secretary Sibelius and US Attorney General Holder

• Members joined from Federal & State government, private payers and associations

• Created operating structures and processes• Established legal framework (e.g., MOU)• Established regular meetings and coordination• Completion of the First Information Exchange

For Limited Distribution

The following disclaimer applies: Regarding all Healthcare Fraud Prevention Partnership communications and activities, this is a purely voluntary activity.  The committees regarding data sharing and analysis;  information sharing; and the Executive Board, are to be used solely as discussion groups where the individual members can share facts or information or individual input.  No group or consensus advice or recommendations will be given by the partners in the committees or the Executive Board.  In addition, no policy-making or decision-making will be performed by the committees or the Executive Board.  The

Secretary and the Attorney General or their designees will make the final policies or other decisions.

CURRENT PARTNERSHIP AS OF APRIL 1, 2013

Federal Partners• Department of Health and Human Services, Associate Deputy

Secretary’s Office• Department of Health and Human Services, Centers for

Medicare and Medicaid Services• Department of Health and Human Services, Office of the

Inspector General• Department of Justice, Criminal Division• Department of Justice, Federal Bureau of Investigations

 State Partners• Arizona Medicaid Office of the Inspector General, Arizona Health

Care Cost Containment System• New York Office of Medicaid Inspector General • Iowa Insurance Fraud Bureau (NAIC’s representative on the

Information Sharing Committee) • Ohio Attorney General’s Office (NAMFCU’s representative on the

Information Sharing Committee)• Kansas Attorney General’s Office (NAMFCU’s representative on

the Executive Board) 

Private Payers • Aetna• Amerigroup • Blue Cross and Blue Shield of Alabama • Blue Cross and Blue Shield of Louisiana • Humana • Independence Blue Cross • Travelers • Tufts Health Plan • United HealthCare• WellPoint

Associations• America's Health Insurance Plans (AHIP)• Blue Cross and Blue Shield Association

(BCBSA)• Coalition Against Insurance Fraud (CAIF)• National Association of Insurance

Commissioners (NAIC)• National Association of Medicaid Directors

(NAMD)• National Association of Medicaid Fraud Control

Units (NAMFCU)• National Health Care Anti-Fraud Association

(NHCAA)• National Insurance Crime Bureau (NICB)

For Limited Distribution

The following disclaimer applies: Regarding all Healthcare Fraud Prevention Partnership communications and activities, this is a purely voluntary activity.  The committees regarding data sharing and analysis;  information sharing; and the Executive Board, are to be used solely as discussion groups where the individual members can share facts or information or individual input.  No group or consensus advice or recommendations will be given by the partners in the committees or the Executive Board.  In addition, no policy-making or decision-making will be performed by the committees or the Executive Board.  The

Secretary and the Attorney General or their designees will make the final policies or other decisions.

STRUCTURES OF THE HFPP

Executive Board

Information Sharing Committee (ISC)

Data Analysis & Review Committee (DARC)

Study 1 Study 2 Study 3 Study 4 Study 5

Trusted Third Party

Life CycleTeam

Study Pipeline

Team

TTP Strategy

TTP NASAChallenge

Other Teams

Fo

rmal

S

tru

ctu

res

Stu

die

sP

lan

nin

g

Team

s

For Limited Distribution

The following disclaimer applies: Regarding all Healthcare Fraud Prevention Partnership communications and activities, this is a purely voluntary activity.  The committees regarding data sharing and analysis;  information sharing; and the Executive Board, are to be used solely as discussion groups where the individual members can share facts or information or individual input.  No group or consensus advice or recommendations will be given by the partners in the committees or the Executive Board.  In addition, no policy-making or decision-making will be performed by the committees or the Executive Board.  The

Secretary and the Attorney General or their designees will make the final policies or other decisions.

DATA SHARING CONCEPT

Trusted Third Party

Government Partner #1

Government Partner #2

Private Payer #....

Private Payer #2

Private Payer #1

• Study Selection

• Design & Planning

• Data Exchange• TRUSTED 3rd PARTY

• Partner Data Analysis & Actions

• Evaluation

For Limited Distribution

The following disclaimer applies: Regarding all Healthcare Fraud Prevention Partnership communications and activities, this is a purely voluntary activity.  The committees regarding data sharing and analysis;  information sharing; and the Executive Board, are to be used solely as discussion groups where the individual members can share facts or information or individual input.  No group or consensus advice or recommendations will be given by the partners in the committees or the Executive Board.  In addition, no policy-making or decision-making will be performed by the committees or the Executive Board.  The

Secretary and the Attorney General or their designees will make the final policies or other decisions.

ISC – EXTENT OF INFORMATION SHARING

General Public

HFPP Partner Extensions (e.g.

association members)

HFPP Full Partnership

Participating Entities

Each individual HFPP data exchange study will be analyzed to determine:

1. What level of data will reach each level?

2. What products will reach each level?

3. What special actions or considerations are needed for this data exchange?

4. How do we measure success?

For Limited Distribution

The following disclaimer applies: Regarding all Healthcare Fraud Prevention Partnership communications and activities, this is a purely voluntary activity.  The committees regarding data sharing and analysis;  information sharing; and the Executive Board, are to be used solely as discussion groups where the individual members can share facts or information or individual input.  No group or consensus advice or recommendations will be given by the partners in the committees or the Executive Board.  In addition, no policy-making or decision-making will be performed by the committees or the Executive Board.  The

Secretary and the Attorney General or their designees will make the final policies or other decisions.

DARC - CONCEPTUAL STUDY LIFE CYCLE

Stage: Study Selection• Study Proposal• Selection Criteria• Prioritized into

Pipeline

Stage: Design & Planning• Data Design• Participating Entities• Planning Logistics

Stage: Execution & Analysis• Moderated Exchange• Aggregation & Results• Analysis• Corroboration• Iteration

Stage: Outcomes Measurement• Process &

Operational• Outcomes

For Limited Distribution

The following disclaimer applies: Regarding all Healthcare Fraud Prevention Partnership communications and activities, this is a purely voluntary activity.  The committees regarding data sharing and analysis;  information sharing; and the Executive Board, are to be used solely as discussion groups where the individual members can share facts or information or individual input.  No group or consensus advice or recommendations will be given by the partners in the committees or the Executive Board.  In addition, no policy-making or decision-making will be performed by the committees or the Executive Board.  The

Secretary and the Attorney General or their designees will make the final policies or other decisions.

DARC STUDY PIPELINE AND OVERLAP WITH CONCEPTUAL STUDY LIFE CYCLE

Stage: Study Selection•Study Proposal•Selection Criteria•Prioritized into Pipeline

Stage: Design & Planning•Data Design•Participating Entities•Planning Logistics

Stage: Execution & Analysis•Moderated Exchange•Aggregation & Results•Analysis•Corroboration• Iteration

Stage: Outcomes Measurement•Process & Operational•Outcomes

Pipeline Tiger Team will:

Document Study Concepts;

Prioritize Concepts;

Recommend Studies.

For Limited Distribution

The following disclaimer applies: Regarding all Healthcare Fraud Prevention Partnership communications and activities, this is a purely voluntary activity.  The committees regarding data sharing and analysis;  information sharing; and the Executive Board, are to be used solely as discussion groups where the individual members can share facts or information or individual input.  No group or consensus advice or recommendations will be given by the partners in the committees or the Executive Board.  In addition, no policy-making or decision-making will be performed by the committees or the Executive Board.  The

Secretary and the Attorney General or their designees will make the final policies or other decisions.

DARC - STUDY PIPELINE AND OVERLAP WITH CONCEPTUAL STUDY LIFE CYCLE

Stage: Study Selection•Study Proposal•Selection Criteria•Prioritized into Pipeline

Stage: Design & Planning•Data Design•Participating Entities•Planning Logistics

Stage: Execution & Analysis•Moderated Exchange•Aggregation & Results•Analysis•Corroboration• Iteration

Stage: Outcomes Measurement•Process & Operational•Outcomes

Pipeline Tiger Team will:

Coordinate Intended Study Concepts with Technical Sub Groups

For Limited Distribution

The following disclaimer applies: Regarding all Healthcare Fraud Prevention Partnership communications and activities, this is a purely voluntary activity.  The committees regarding data sharing and analysis;  information sharing; and the Executive Board, are to be used solely as discussion groups where the individual members can share facts or information or individual input.  No group or consensus advice or recommendations will be given by the partners in the committees or the Executive Board.  In addition, no policy-making or decision-making will be performed by the committees or the Executive Board.  The

Secretary and the Attorney General or their designees will make the final policies or other decisions.

EARLY ACTIVITIES OF THE PARTNERSHIP

• The first information exchange has occurred (more information discussed on the next slide).

• Sharing this information is considered a major milestone in the maturation of the HFPP and tested the process for data exchange

• Participating partners are evaluating the results for use and value in their individual programs

• Participating partners were limited due to legal constraints

For Limited Distribution

The following disclaimer applies: Regarding all Healthcare Fraud Prevention Partnership communications and activities, this is a purely voluntary activity.  The committees regarding data sharing and analysis;  information sharing; and the Executive Board, are to be used solely as discussion groups where the individual members can share facts or information or individual input.  No group or consensus advice or recommendations will be given by the partners in the committees or the Executive Board.  In addition, no policy-making or decision-making will be performed by the committees or the Executive Board.  The

Secretary and the Attorney General or their designees will make the final policies or other decisions.

FIRST INFORMATION EXCHANGE• 11 Partners Contributed

• 2 Federal• 1 State• 1 Private Association• 7 Private Payers

• 3 Information Types• >1400 Misused

Codes• >100 Fraud

Schemes• >44 Data Sources

• Partner analysis yielded various interesting findings

First Informat

ion Exchan

ge

Misused

Codes

Fraud Schem

es

Data Source

s

For Limited Distribution

The following disclaimer applies: Regarding all Healthcare Fraud Prevention Partnership communications and activities, this is a purely voluntary activity.  The committees regarding data sharing and analysis;  information sharing; and the Executive Board, are to be used solely as discussion groups where the individual members can share facts or information or individual input.  No group or consensus advice or recommendations will be given by the partners in the committees or the Executive Board.  In addition, no policy-making or decision-making will be performed by the committees or the Executive Board.  The

Secretary and the Attorney General or their designees will make the final policies or other decisions.

EXAMPLES OF SHARED INFORMATION: MISUSED CODES & FRAUD SCHEMES

For Limited Distribution

The following disclaimer applies: Regarding all Healthcare Fraud Prevention Partnership communications and activities, this is a purely voluntary activity.  The committees regarding data sharing and analysis;  information sharing; and the Executive Board, are to be used solely as discussion groups where the individual members can share facts or information or individual input.  No group or consensus advice or recommendations will be given by the partners in the committees or the Executive Board.  In addition, no policy-making or decision-making will be performed by the committees or the Executive Board.  The

Secretary and the Attorney General or their designees will make the final policies or other decisions.

THE FUTURE OF THE PARTNERSHIP

• Build the Trusted Third Party & necessary technical capabilities

• Active pipeline of studies & data exchanges• Legal agreements and other necessary policies• Identifiable data exchanges• Best practices and information sharing

• Expanded membership & fraud-fighting capabilities

For Limited Distribution

The following disclaimer applies: Regarding all Healthcare Fraud Prevention Partnership communications and activities, this is a purely voluntary activity.  The committees regarding data sharing and analysis;  information sharing; and the Executive Board, are to be used solely as discussion groups where the individual members can share facts or information or individual input.  No group or consensus advice or recommendations will be given by the partners in the committees or the Executive Board.  In addition, no policy-making or decision-making will be performed by the committees or the Executive Board.  The

Secretary and the Attorney General or their designees will make the final policies or other decisions.

DATA SHARING OPERATIONAL MILESTONES

CY ‘13 Q1 CY ‘13 Q3CY ‘13 Q2 CY ‘13 Q4

De-Identified Information Sharing (i.e. Best Practices, Fraud Schemes)

Proof of Concept for Identified Information Exchange

Dat

a Sh

arin

gBu

sine

ss F

ram

ewor

kTe

chni

cal

Fram

ewor

k Launch Trusted Third PartyDevelop Trusted Third Party Strategy

Leverage Interim Trusted Third Party

Technical Prototyping

Fully established framework for identified information exchange

CMS Business Framework CMS Delegation of Authority – Authority for CMS to exchange information with private partners CMS System of Record Notice – Requirement for aligning CMS systems with data exchange needs CMS Umbrella Paperwork Reduction Act Clearance – Permits expansion beyond 9 private

participating entities

Partner and Participating Entity Framework Memoranda of Understanding – Establishes principles of the partnership Business Associate Agreements – Legal agreements to allow sharing of identified data

For Limited Distribution

The following disclaimer applies: Regarding all Healthcare Fraud Prevention Partnership communications and activities, this is a purely voluntary activity.  The committees regarding data sharing and analysis;  information sharing; and the Executive Board, are to be used solely as discussion groups where the individual members can share facts or information or individual input.  No group or consensus advice or recommendations will be given by the partners in the committees or the Executive Board.  In addition, no policy-making or decision-making will be performed by the committees or the Executive Board.  The

Secretary and the Attorney General or their designees will make the final policies or other decisions.

Questions Questions

Questions? Please enter questions into the

Question or Chat pods in the GoToMeeting webinar

interface or please send us an email at:

MEDIC-Outreach@RainmakersSolutions.com

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