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

3

3

2

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1Claim

4

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