Medicare-Medicaid Network Analysis

1 / 28 OCTOBER 2007 / SGS INTERNAL

Medicare-Medicaid Network AnalysisJamie Lejcar

Andrew Needs

Medicare/Medicaid Data Analysis Center

2 / 28 OCTOBER 2008 / SGS INTERNAL Medicare-Medicaid Network Analysis

Outline

•Gap Analysis

• Integration

•Statistical Models

•Provider Profiles


Gap Analysis


•Medicare– Medicare pays a travel fee for specimen collection

in nursing homes.• P9603 – Per Mile• P9604 – Per Trip

•Medicaid– Medicaid does not pay a travel fee for specimen

collection of nursing home recipients

Utilization – Gap Analysis


Utilization – Gap Analysis

•Medicare– Does not pay:– Very Low Density Lipoprotein (VLDL) CPT – 83719– Lipoprotein CPT – 82172

•Medicaid– CPT – 82172 and 83719 are reimbursable in

certain circumstances


Utilization Gap Analysis

NY Medicaid - CPT 82172Apolipoprotein Test

$0

$500

$1,000

$1,500

$2,000

$2,500

1 2 3 4 1 2 3 4

2006 2006 2006 2006 2007 2007 2007 2007



NY Medicaid - CPT 83719Very Low Density Lipoprotein

$0

$20

$40

$60

$80

$100

$120

$140

$160

1 2 3 4 1 2 3 4

2006 2006 2006 2006 2007 2007 2007 2007


Utilization - Gap Analysis

•Look for potential unbundling

•Multiple Ferritin / Iron tests (82728, 83550 and 83540) paid on the same date of service.

•Glycated Protein (82985) and Glycosylated Hemoglobin (83036) on the same date of service.



NY Medicaid - CPT CodesFerritin / Iron Testing

$0$5,000

$10,000$15,000$20,000$25,000$30,000$35,000$40,000

1 2 3 4 1 2 3 4 1 2

2006 2006 2006 2006 2007 2007 2007 2007 2008 2008

82728 83540 83550



NY Medicaid - CPT CodesGlycated Protein / Hemoglobin Testing

$0$20,000$40,000$60,000$80,000

$100,000$120,000$140,000$160,000$180,000$200,000

1 2 3 4 1 2 3 4 1 2

2006 2006 2006 2006 2007 2007 2007 2007 2008 2008

82985 83036


Integration of Medicare and Medicaid

•New York Medicaid Lab Payments– Medicare pays 100% (no co-insurance necessary)

– Data integration identifies co-insurance payments in Medicaid

– 500,000 claims; $4.2 million in potential Medicaid savings


Our Medi-Medi Approach - FUSION Model


Integration


Integration of Medi-Medi Data

• Identify billing aberrancies that can be missed when analyzing only Medicare or Medicaid data– Challenges involved:

• Crossover Claims

– Use of data analysis tools (SAS, JMP, i2, etc.) to identify Medi-Medi aberrancies and networks


Integration Example – Impossible Days

Provider X Impossible Days

0

20

40

60

80

100

120

140

Medicare Medi-Medi Medicaid

Program

Nu

mb

er

of

Days


Specific Examples – Provider X

Integration Example – Impossible Days


Statistical Models


Spike Models

•Analyzed regularly to detect sudden upward shifts in provider billing and/or paid amounts

•Can be specific to one provider specialty or many

•Spikes identified are studied more closely to determine if they are explainable– New provider PIN, legitimate business growth, etc.


Spike Models - Example

Lab A - Medicare Earnings by Month

$-

$20,000

$40,000

$60,000

$80,000

$100,000

$120,000

$140,000

$160,000

$180,000


Spike Models - Example

•Lab A– Identified through aberrancies in spike model

– Further analysis uncovered additional “red flags”:• Referring providers with no rendering claims• Claims paid with invalid referring UPIN• Billing irregularities with travel codes (P9603, P9604)


Referring Provider Analysis

•Lab A submitted claims with 443 different referring UPINs in 2006– Analysis involved matching Lab A’s billing data with each referring

provider’s billing data• 89 of the 443 (20.1%) referring providers had no billing history for

referred beneficiaries• $954,234 (54%) of Lab A’s paid dollars stemmed from these 89

non-rendering providers

– An additional $119,265 (4.8% of total paid dollars) was paid to Lab A in 2006 on claims with invalid referring UPINs


Referring Provider Analysis

2006 Referring UPIN Types - Lab A

5%

49%

46%

Invalid

Valid, Non-Rendering

Valid, Rendering


Referring Network Analysis


Travel Procedures

• For travel reimbursement, Medicare uses procedures P9603 and P9604– Used when lab employees travel to nursing home for specimen

collection• Lab employee has to draw specimen

– P9603: Billed per mile (greater than 20 miles)

– P9604: Billed per trip (less than 20 miles)

2006 Travel Fee Schedule

Code Fee

P9603 $0.94

P9604 $12.04


Travel Procedures

Unique Locations of Service per Day – Lab A


“Bill and Run” Scheme

•Scheme:– Providers open a PIN, bill Medicare/Medicaid

heavily, then stop suddenly• Once spike model detects the spike, provider is

gone• Need more specialized model to focus on new

providers

•“Bill and Run” model:– Analyzed all PINs opened in a given timeframe– Reviewed monthly billing amounts to detect

sudden stops in billing– Added a more real-time approach to fraud

detection


Billing Pattern

"Bill and Run" Pattern

$0

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

$7,000

5/1/

2007

5/8/

2007

5/15

/200

7

5/22

/200

7

5/29

/200

7

6/5/

2007

6/12

/200

7

6/19

/200

7

6/26

/200

7

7/3/

2007

7/10

/200

7

7/17

/200

7

7/24

/200

7

7/31

/200

7

8/7/

2007

8/14

/200

7

8/21

/200

7

8/28

/200

7

9/4/

2007

9/11

/200

7

9/18

/200

7

9/25

/200

7

Date of Service

Dollars

Bille

d


Provider Profile Report

•Report summarizes provider’s use of procedure codes– Compares given provider’s usage to his/her peer

group (i.e. same specialty)

•Statistics are calculated to identify potential aberrancies with the provider’s billing patterns



• Initial figures describe provider’s use of various procedure codes

76536 9 439 $ 768.24 9 $ 960.30 85651 206 439 $ 1,329.28 265 $ 1,329.28 90765 57 439 $ 10,056.09 129 $ 12,703.92 99243 64 439 $ 7,420.78 70 $ 10,135.30 99212 107 439 $ 6,226.43 181 $ 8,352.87 36415 257 439 $ 2,642.10 880 $ 2,643.00 99238 66 439 $ 6,184.59 96 $ 7,738.56 80053 245 439 $ 5,853.21 593 $ 5,853.21 81003 175 439 $ 590.32 188 $ 590.32 93000 188 439 $ 6,922.32 276 $ 9,259.80 J0885 75 439 $ 96,452.16 327 $ 120,624.06 85025 254 439 $ 8,697.77 798 $ 8,698.86

Allowed Services

Allowed Charges

# of Patients

Procedure Code

Total Patients

Provider Paid Amt

PIN '123456' for 1st Half 2006



76536 2.05% 0.87% 0.0205 0.0087 1.00 1.00 3.5 0.09185651 46.92% 8.07% 0.6036 0.0532 1.29 0.57 0.396 -0.2490765 12.98% 2.21% 0.2938 0.0426 2.26 2.46 0 099243 14.58% 3.38% 0.1595 0.0306 1.09 0.98 0.168 0.31599212 24.37% 6.39% 0.4123 0.0839 1.69 1.23 -0.478 0.44436415 58.54% 34.52% 2.0050 0.5976 3.42 1.60 -0.114 2.03699238 15.03% 5.35% 0.2187 0.0589 1.46 1.07 0.054 0.23580053 55.81% 19.65% 1.3510 0.3092 2.42 1.17 0.499 0.18881003 39.86% 7.49% 0.4282 0.0857 1.07 1.00 -0.06 0.40693000 42.82% 13.63% 0.6287 0.1518 1.47 0.99 0.355 0.365J0885 17.08% 6.44% 0.7449 0.1737 4.36 3.06 0 085025 57.86% 33.26% 1.8180 0.5686 3.14 1.52 -0.01 6.096

Ratio CPeer Ratio A

Procedure Code

Peer Ratio B

Peer Ratio C

Peer % of Patients

% of Patients

Ratio A Ratio B

•Ratios are calculated to compare provider to his/her peer group



•“Z-scores” calculated to determine a standardized difference between provider and peer group

76536 1.73 1.52 1.52 0 16.77 21.5585651 4.69 3.38 4.52 1.6 1.26 15.4690765 5.52 3.07 4.15 -0.06 0 12.6899243 6.79 1.24 2.03 0.6 -0.1 10.5799212 6.45 1.49 1.99 0.73 -0.4 10.2636415 4.06 0.87 2.27 2.39 -0.08 9.5299238 4.23 1.38 2.04 1.83 -0.18 9.380053 3.27 1.68 1.98 1.92 0.29 9.1481003 3.35 2.99 2.41 0.27 -0.21 8.8193000 3.64 1.31 1.76 2.09 0 8.8J0885 4.63 1 2.36 0.63 0 8.6285025 3.28 1.11 2.28 2.03 -0.14 8.56

SDs - Allowed

SDs - % of Patients

SDs - Ratio A

Procedure Code

SDs - Ratio B

SDs - Ratio C

SUM - Std Deviations


Questions


Contact Information

Jamie Lejcar

717-763-5923

[email protected]

Andrew Needs

717-975-5466

[email protected]


SafeGuard Services, LLC5400 Legacy DrivePlano, TX 75024

Medicare-Medicaid Network Analysis

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