Transcript Slide 1

Eliminating Waste, Fraud, and
Abuse in Public Programs:
Indiana’s 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
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Define the Problem
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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)
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Indiana’s Systematic Approach to
Combating Improper Payments
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Current Program Integrity Efforts
Recoveries & Avoidances SFY 11
Program
Third Party Liability
Estate Recovery
Pharmacy Audits
Surveillance and Utilization
Long Term Care
Total Program Integrity
Efforts
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Dollars
$
$
112,417,070
12,199,259
$
$
$
$
3,828,569
2,341,263
170,192
130,956,353
5
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
Penalties
– Recovered $36,098,607
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New Program Integrity Strategy
Expand program integrity efforts in Indiana
Establish strong partnership with innovative
Fraud and Abuse Detection System (FADS)
contractor
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
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Focus on Results
Implement FADS on-time
Improve financial return on investment
 Recoveries and cost avoidance
Enhance provider relations
Advance program integrity effectiveness
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Prevention: Provider
Improper Payments
• 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
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Prevention: Member
Misrepresentation & Overutilization
• Eligibility data matches
– Pre-enrollment and redetermination
• ACA eligibility data in 2014
– Access to federal databases to validate eligibility
• Member fraud hotline
– For both members and providers
• Right Choices Program (RCP)
– Controls members utilization
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Detection: Improper Payments
• Continual, rigorous data analysis and
investigation
– Primary focus on Medicaid claims data
– Link data across multiple sources
• Use advanced data mining techniques and
algorithms
– DataProbe
– J-SURS
– Other Software Tools
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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
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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
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Restricted Card Becomes
Right 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
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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
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Current Right Choices Program
Enrollment Methodology
1. Overutilization of ER, # of PMP selections,
# of Prescribers, # of Pharmacies
2. Overutilization of Controlled Substances
together with multiple prescribers and
pharmacies
3. Automatic placement due to suspected or
alleged fraud or State guidelines for mental
health drugs
a)
b)
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Five or more mental health drug claims in 45 days
Benzodiazepines from three or more prescribers in 90 days
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RCP Program Ramp-up
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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 parameters
– Members with xs ER utilization plus 2 other parameters
– Members with xs ER utilization plus 1 other parameter
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Duration Study – Right Choices Program
Run date: 3/7/2011
Total Amount Paid Per Member Per Month
$1,000
Enrolled in Restricted Card
Program
$900
$800
$700
$600
$500
$400
+12 Month
+11 Month
+10 Month
+09 Month
+08 Month
+07 Month
+06 Month
+05 Month
+04 Month
+03 Month
+02 Month
+01 Month
-01 Month
-02 Month
-03 Month
-04 Month
-05 Month
-06 Month
-07 Month
-08 Month
-09 Month
-10 Month
-11 Month
$200
-12 Month
$300
Results illustrate average monthly utilization for enrollees by duration starting 12 months prior to RCP effective date.
Results for later durations are influenced by demographic/morbidity changes underlying the reduction in study lives in late
durations.
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Right Choices Program
Run date: 03/07/2011
Amount Paid Per Member Per Month - ER Only
$35
Enrolled in Restricted Card
Program
$30
$25
$20
$15
+12 Month
+11 Month
+10 Month
+09 Month
+08 Month
+07 Month
+06 Month
+05 Month
+04 Month
+03 Month
+02 Month
+01 Month
-01 Month
-02 Month
-03 Month
-04 Month
-05 Month
-06 Month
-07 Month
-08 Month
-09 Month
-10 Month
-11 Month
$5
-12 Month
$10
Results illustrate average monthly utilization for enrollees by duration starting 12 months prior to RCP effective date. Results for
later durations are influenced by demographic/morbidity changes underlying the reduction in study lives in late durations.
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Right Choices Program
Run date: 03/07/2011
Amount Paid Per Member Per Month - Dr. Office Visit Only
$90
Enrolled in Restricted Card
Program
$80
$70
$60
$50
$40
$30
$20
Results illustrate average monthly utilization for enrollees by duration starting 12 months prior to RCP effective date. Results for later
durations are influenced by demographic/morbidity changes underlying the reduction in study lives in late durations.
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+12 Month
+11 Month
+10 Month
+09 Month
+08 Month
+07 Month
+06 Month
+05 Month
+04 Month
+03 Month
+02 Month
+01 Month
-01 Month
-02 Month
-03 Month
-04 Month
-05 Month
-06 Month
-07 Month
-08 Month
-09 Month
-10 Month
-11 Month
$0
-12 Month
$10
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Right Choices Program
Run date: 03/07/2011
Scripts - Per Member Per Month
7
Enrolled in Restricted Card
Program
6
5
4
3
+12 Month
+11 Month
+10 Month
+09 Month
+08 Month
+07 Month
+06 Month
+05 Month
+04 Month
+03 Month
+02 Month
+01 Month
-01 Month
-02 Month
-03 Month
-04 Month
-05 Month
-06 Month
-07 Month
-08 Month
-09 Month
-10 Month
-11 Month
1
-12 Month
2
Results illustrate average monthly utilization for enrollees by duration starting 12 months prior to RCP effective date. Results for later
durations are influenced by demographic/morbidity changes underlying the reduction in study lives in late durations.
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Why is the RCP Important in
Managed Care Environments?
•
•
•
•
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%
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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
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Conclusion
Thank you for your interest
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