Stop Fraud Before It Occurs Through Technology and

Human Touch Terri Williams, President and CEO, Mains’l Services, Inc.;

John Van Wingen, Assistant Dean of Information Technologies, FL State University Medical School;

Jim Young, President and CEO Independent Systems and Solutions, Inc.;

Pam Erkel, Manger, Special Projects Disability Services Division, MN Dept. of Human Services; and

Linda Joyce, Deputy Director, Division of Long Term Services and Supports, CMS

The Devil is in the Details Solid Program Design establishing clear rules,

clear expectations Comprehensive training up front identifying

roles, rights and responsibilities Access to ongoing tutorials and personal and

online support Systems designed to prohibit bad choices

“The System is Our Savior”

The less fingers that touch it, the less likely it will go missing

Participants and their Attendants must be trained to do the right thing

The system can immediately identify a bad entry preventing fraud before it happens

Prevention is just a phone call away

Sinners and Saints (points where potential fraud occurs)

Trust but verify, or “Inspect what you expect” Often times potential “Sinners” can be identified

during the enrollment process Saints can become sinners if the rules, rights and

responsibilities are not enforced Incentivize people in your system to report

irregularities and give them tools to correct them Our experience is that most participants and

caregivers are Saints

Fraud Fable I Mother enrolls daughter as attendant without

her knowledge IRS sends the daughter a notice of additional

taxes owed The daughter gets in touch with Mains’l

Services and claims no knowledge of income County and Police were notified, internal

investigation commenced

The Moral to the Story

Mains’l terminated family from the program When fraud was committed, paper systems in

place; less likely now with electronic time capture, approval and adjudication, unless there is true criminal intent

We require direct deposit or pay card issued to attendant with unique identifier

Cross check accounts up front

Fraud Fable II Family with two daughters enrolled in personal

supports program Massage therapy authorized in plan of care Mom reimbursed therapist directly, Mains’l

reimbursed mom Mains’l and County concerned that all was not

as it seemed Mains’l discovered that the therapist did not

exist

The Moral to this Tired Tale? Do not reimburse participants directly, require

payments go directly to who they choose for services

Require proof of licensure, certification, and related business documentation from vendors, prior to commencing services

Do not reimburse participants directly for goods, procure them on their behalf instead

“Show Me the Money” “People keep telling us about their love

affairs, when what we really want to know is how much money they make and how they manage on it.”

- Mignon McLaughlin, The Neurotic’s

Handbook, (1963)

It’s My Story and I’m Sticking To It! Fraud in HCBS PDS programs is largely

preventable.

It requires disciplined program design and execution, disciplined use of technology, discipline in how we train participants in the program and lead the attendants performing the work.

TCWilliams@mainsl.com

Fraud Prevention •Concerns of Fraud tend to be

•How extensive is the evidence of Fraud •How much does the Fraud cost the Organization •Is the cost high enough to warrant pursuing the fraudulent people •What can be done to recover the lost dollars •Finally what can be altered to reduce the occurrence

•Models of why the person engages in fraudulent behavior •Economic model

•Economic gain can be achieved by perpetuating the fraud •The penalty for being caught is weighed against the chance for gain •The calculus makes engaging in the behavior worthwhile

•Social Science Model •Milieu encourages fraud •Everyone else does it, so I do it (diffusion)

Fraud Prevention – PCS OIG Report

•Concerns •Improper Payments linked to lack of compliance •Inadequate Controls to Ensure Proper Payment and Quality of Care •PCS is a growing concern

“Investigators have noted that self-directed Medicaid service models (i.e., those in which beneficiaries have decision making authority over certain services and take direct responsibility for managing their services with the system of available supports), especially those that allow beneficiaries significant control over the selection and payment of PCS attendants, are particularly vulnerable to these fraud schemes.” OIG Report, “Personal Care Services, Trends, Vulnerabilities, and Recommendation for Improvement: A Portfolio,” November 2012, p ii.

Patient (Consumer) Care Perspective

•Concerns •Health Care costs more in the US than any other country and is rising •Our understanding of disease has increased exponentially •Yet outcome measures (infant mortality rates, life expectance, and so forth) the US is near the bottom of the industrialized nations as it has been since the 1970’s

•Models of why •Economic model - shifts incentives

•NIH funding for academic research •Insurance coverage – cost shift to government and employers •Procedure based reimbursement shifts from primary to specialties

•Social Science model •Scientific culture belief that biomedical research will eliminate disease

•Pharmaceutical solutions •Acute care focus

•Cultural belief that health care is a right

Patient (Consumer) Care Perspective

•Shift toward outcomes •Shift toward chronic care •Shift toward prevention •Shift toward patient participation •Shift toward transparency

•Patient Centered Outcome Research -- funding of comparative clinical effectiveness research that will give patients and those who care for them the ability to make better-informed health decisions. (See http://pcori.org/) •Physician Competency Resource Set (See, https://www.aamc.org/initiatives/cir/about/348808/aboutpcrs.htmlz)

•Patient centered care one of eight major competencies

“OIG work has demonstrated that existing program safeguards intended to ensure medical necessity, patient safety, and quality and prevent improper payments were often ineffective.” OIG Report, “Personal Care Services, Trends, Vulnerabilities, and Recommendation for Improvement: A Portfolio,” November 2012, p ii.

Technology Changes Permit Different Approaches

•Camera Technology •Photos are now cheap, stored digitally and each photo identifies the time taken and the camera or device that was used. Photos are sent continually over the internet via texting, facebook and emails.

•GIS systems (Geographical Information Systems) •It is now easy to identify the longitude and latitude of any address within an accuracy of several feet. This includes mobile devices. Friends can track each other

•Telehealth •Secure FDA approved systems now exist for telecommunications between patients and health care professionals including sharing of protected healthcare information

•Mobile Health •Use of mobile devices to support health -- examples, stethoscopes, EKG reads, scales, scopes, monitoring devices

•The Internet of Things •Developments that will permit the devices to communicate with each other

But Technology Should Be a Tool Not the Solution Typical considerations to avoid bleeding edge:

•What is the purpose? •Does it integrate with the system? •Is the technology just cool or is it useful? •Does it cost too much? • Will it be adopted by the user?

The most important consideration in developing solutions is the Why

Why

How

What

http://www.ted.com/talks/simon_sinek_how_great_leaders_inspire_action.html

The WHY: Consumer Centered v. Fraud Perspective

Consumer Centered Fraud

Problem Outcomes are bad for Consumer

Consumers and Caregivers Scheme

Focus Systems as a whole Payment

Consumer’s Role

Need input and participation

Need Control

Technology’s Role

Increase opportunities Decrease options for Abuse

Key Implementation Issues

Transparency Training Integration of Systems

Certification Standardization Adequate penalties

Conclusions • Inefficient systems increase the likelihood of inappropriate outcomes • Inappropriate payments may occur

• Scheming • Inefficient systems

• Increasing the Efficiency and Effectiveness of the system requires • Training of participants and users • Clear understanding of procedures • Data Systems that follow work flow and are appropriately

designed • Monitoring for quality control and improvement • Use of technological innovations as a tool not a solution

• Focusing on outcomes, efficiency, and effectiveness will • Enhance transparency • Diminishes the opportunities for fraud

Data Doesn’t Lie

Early Days • We were involved in the finalization of the

Robert Woods Johnson Grant for research into Cash & Counseling. The purpose of the project was to determine if Participants can be in control of their own services and the budgets associated with those services.

The Result

•The result of the study determined that Participants could manage their own services

Early systems failed to provide Integrity of Data.

• Poorly designed systems allowed unintentional fraud.

• Disconnect between Worker and Participant allowed the payments to be made for the wrong Participant.

• Delay in payments and rebilling with no duplication check allowed double payments

Early systems failed to provide Integrity of Data. • Poorly identified Worker allows the

wrong worker to be paid and when the right worker resubmits allows duplication of payments.

• Disconnects between budget modules and timesheet/invoice/reimbursement transaction processing modules

Analysis based on true requirements • Analysis has to be done to uncover the

true requirements and work flow. • Without a true requirements analysis,

systems will be designed incorrectly and will lead to inefficiencies and inappropriate payments that have the appearance of fraud but could be unintentional.

Without thinking about Fraud Prevention we built systems that by the nature of their design prevented inadvertent Fraud.

•Careful analysis of systems requirements lead to the development of a true claims adjudication process

Clearly defined Business Rules (Adjudication)

• Is Participant Eligible for services? - In the hospital, No Medicaid eligibility

• Is the Provider approved? – Passed Background check, assigned to the Participant

Clearly defined Business Rules (Adjudication)

• Is the service appropriate? – Glasses for a blind Participant, Quantity in-appropriate

• Is the service listed on the approved list of services, Budget

• Will this service exceed monthly/yearly budget limits

Clearly defined Roles • Who can enter time and when • Who can approve/disapprove/hold

timesheets/invoices

Development of Budget System

•Strongly enforced Budget Rules •Budgets comply with State and Federal requirements

Additionally the nature of Participant Directed Systems Required more controls

• On-Line Documentation of Service Details • Detail level activities captured at the time of

entry that documents services

More controls

• Oversight of Service Providers • IVR verification of caller ID provides

visit verification • Verification that Client is receiving

services, not in the hospital/institution

More controls

• Insurance that provider meets minimum standards/qualifications • Education • Background Checks

What the future holds

What the future holds

• Better coordination between agencies to discover incidents of dual services

What the future holds

• Use of technology to better monitor services, WHO, WHAT, WHEN, WHERE

Use of technology to better monitor services • GPS devices providing location services

for both Providers and Participants WHERE

Use of technology to better monitor services

• Biometric devices allow true verification of identity of Provider and Participant WHO

Use of technology to better monitor services

• Real-time time capture WHEN

Use of technology to better monitor services • So now we know WHO, WHEN and WHERE

how do we tell WHAT they are doing? • Can technology help us??

Minnesota LTSS • Long history of Long Term Supports and Services

including participant directed services

• Robert Wood Johnson grant in mid 1990’s

• Robust Personal Care Attendant (PCA) program

• 5 waivers that include the Consumer Directed Community Supports service option

• Now developing Community First Choice option-1915 (k)

Lessons Learned

• Programs work better when participants are fully informed about their rights and responsibilities

• Support systems are required to assist participants in understanding the PDS option

• Easy to use training and enrollment manuals that help participants understand what is expected of them

Lessons Learned (con’t) • Establish clear provider standards and qualifications

from the beginning

• Measure performance in outcomes not just process

• Identify best practices and integrate into program design (FMS standards, certification)

Work Together • Pay and chase leads to a climate of fear and

frustration

• Create a partnership environment between CMS, state, providers and participants

• Everyone has a role in program integrity and fraud prevention

• Empower participants with knowledge and education up front

Designing Community First Choice 1915 (k) option

• Implementation Council provides a forum to hear what participants and stakeholders want to see in the program and design in best practices

• Also provides a forum for the stakeholders to hear from DHS and OIG about concerns/issues and lessons learned and find solutions together