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Eliminating Waste, Fraud, and Abuse in Public Programs: Indiana


Eliminating Waste, Fraud, and Abuse in Public Programs: Indiana s Promising Practice National Academy for State Health Policy 24th Annual State Health Policy Conference – PowerPoint PPT presentation

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Title: Eliminating Waste, Fraud, and Abuse in Public Programs: Indiana

Eliminating Waste, Fraud, and Abuse in Public
Programs Indianas Promising Practice
National Academy for State Health Policy 24th
Annual State Health Policy Conference October
3-5, 2011 Kansas City, Missouri Emily F.
Hancock, RPh, PharmD, MPA Office of Medicaid
Policy and Planning
Define the Problem
The Problem Illustrated
  • The U.S. spends more than 2 trillion on
    healthcare annually. At least 3 percent of that
    spending or 68 billion is lost to fraud each
    year. (National Health
    Care Anti-Fraud Association, 2008)
  • Medicare and Medicaid made an estimated 23.7
    billion in improper payments in 2007. These
    included 10.8 billion for Medicare and 12.9
    billion for Medicaid. (U.S. Office of
    Management and Budget, 2008)
  • Medicare paid dead physicians 478,500 claims
    totaling up to 92 million from 2000 to 2007.
    These claims included 16,548 to 18,240 deceased
    physicians. (U.S. Senate Permanent
    Committee on Investigations, 2008)

Indianas Systematic Approach to Combating
Improper Payments
Current Program Integrity EffortsRecoveries
Avoidances SFY 11
Program Dollars
Third Party Liability 112,417,070
Estate Recovery 12,199,259
Pharmacy Audits 3,828,569
Surveillance and Utilization 2,341,263
Long Term Care 170,192
Total Program Integrity Efforts 130,956,353
Prosecutions and Restitutions
  • Member Fraud CY2010
  • Bureau Of Investigations (BOI) substantiated 138
    Medicaid Fraud Cases
  • 24 cases were prosecuted
  • 11 received felony convictions
  • Court ordered restitution totaling 24,554
  • Provider Fraud SFY11
  • Medicaid Fraud Control Unit (MFCU) investigated
    266 fraud referrals
  • Prosecuted 12 providers, 10 received Criminal
  • Recovered 36,098,607

New Program Integrity Strategy
  • Expand program integrity efforts in Indiana
  • Establish strong partnership with innovative
    Fraud and Abuse Detection System (FADS)
  • Leverage expertise with State staff working
    alongside contractor
  • Combine technology, expert consulting and
    auditing services
  • Develop new data mining processes
  • Coordinate activities of agency stakeholders

Focus on Results
  • Implement FADS on-time
  • Improve financial return on investment
  • Recoveries and cost avoidance
  • Enhance provider relations
  • Advance program integrity effectiveness

Prevention Provider Improper
  • Provider Enrollment
  • New enrollment processes and risk categories
  • Provider Education
  • Educational seminars, bulletins, and newsletters
  • National Correct Coding Initiative
  • More than 1.3 million new system edits in place
  • Pre-payment Review
  • Validating claims before payment is made
  • New ACA Regulations
  • Mandatory payment suspensions

Prevention Member Misrepresentation
  • Eligibility data matches
  • Pre-enrollment and redetermination
  • ACA eligibility data in 2014
  • Access to federal databases to validate
  • Member fraud hotline
  • For both members and providers
  • Right Choices Program (RCP)
  • Controls members utilization

Detection Improper Payments
  • Continual, rigorous data analysis and
  • Primary focus on Medicaid claims data
  • Link data across multiple sources
  • Use advanced data mining techniques and
  • DataProbe
  • J-SURS
  • Other Software Tools

Reporting Fraud and Abuse
  • i-Sight Case Tracking System
  • Provides workflow-driven solution for
    documentation and tracking of provider and member
    fraud cases
  • Supports information sharing to ensure
    collaboration on cases
  • Allows for timely and accurate reporting of
    results for all Program Integrity activities

Emphasis Member Utilization
  • How to manage resource access, cost and quality
  • How to gain provider buy-in
  • How to operate lock-in program
  • One primary medical provider (PMP)
  • One pharmacy
  • One hospital (for non-emergency visits)
  • How to evaluate return on investment

Restricted Card BecomesRight Choices Program
  • Regulatory Authority
  • Indiana Administrative Code, 405 IAC 1-1-2(c)
  • Program Purpose
  • Identify members who use Medicaid services more
    extensively than peers
  • Implement restrictions for members who would
    benefit from increased care and coordination
  • Restricted Card Program operated from 2000 until
    redesigned RCP launched in 2010

What Changed?
Domain Right Choices Program
Philosophy Interventional
Member Identification And Enrollment Electronic standards for utilization thresholds scoring methodology.
Member Maintenance Uniform policy manual
Member Exit Exit Review Summary with provider involvement
Data Flow and System Integration Web interchange tool and reports
Detecting and Reporting Misuse, Fraud, and Abuse Stakeholder involvement within creation of policy and procedure
Program Evaluation Metrics Nine formalized performance metrics
Current Right Choices Program Enrollment
  • Overutilization of ER, of PMP selections,
    of Prescribers, of Pharmacies
  • Overutilization of Controlled Substances together
    with multiple prescribers and pharmacies
  • Automatic placement due to suspected or alleged
    fraud or State guidelines for mental health drugs
  • Five or more mental health drug claims in 45 days
  • Benzodiazepines from three or more prescribers in
    90 days

RCP Program Ramp-up
Priority Screening and Assessment
  • Members with Utilization at 3rd Standard
    Deviation of the Mean
  • Primary Medical Provider (PMP) selections
  • Emergency Room visits
  • Prescribers
  • Pharmacies
  • Prioritize Screening and Assessment
  • Members with xs ER utilization plus 3 other
  • Members with xs ER utilization plus 2 other
  • Members with xs ER utilization plus 1 other

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Why is the RCP Important in Managed Care
  • Focuses coordinated care
  • Encourages medical home concept
  • Leverages case management impact
  • Reduces waste, fraud, and abuse
  • Total amount paid - ?257.56 pmpm
  • Amount paid - ER visits - ?44
  • Amount paid - physician office visits ?48
  • Pharmacy claim count ?2

Future Considerations
  • Automated review of Medicaid application data
  • Automated pre-payment review of claims
  • Emerging technology application
  • Right Choices Program expansion
  • Consequences for Medicaid program violation

  • Thank you for your interest
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