Transcript Glen Schuster`s Presentation

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Program Integrity:
Fraud & Abuse
Glendon Schuster
Senior Vice President and Chief Technology Officer
Alliance for Health Reform Panel Briefing
March 5, 2012
“It is the policy of Centene Corporation to
conduct its business affairs in
accordance with the standards and
rules of ethical business conduct and
to abide by all applicable laws, both in
letter and spirit.
In this, there is no compromise.”
- Michael F. Neidorff
Chairman, President and CEO
Program Integrity at Centene
Supporting Program Integrity
 Conventional Methods
 Preventive Approach
Program Integrity –
Conventional Methods
Prepayment Reviews
– Billing Patterns
• System Edits
• Strategic
Partnerships
Post Payment
Investigations
• Data Mining
• Provider Profiling
• Referrals
Member Reviews
• Data Mining
• Service Validation
Centelligence™
Through Centelligence™ we take our conventional methods
of Program Integrity to the next level.
4
Centene Preventive Approach
Health Information
Technology
Provider
Partnerships
Demand for faster, more
accurate payment
provides opportunities
for engagement.
Coordinated
Care
Collaboration with
our State Partners
Centene Preventive Approach
• Health Information Technology (HIT)
– Administrative Efficiency / Electronic Data Interchange (EDI)
– Electronic Health Records, Member Health Records, Personal
Health Records, Health Information Exchange
• Provider Partnerships
– Provider Support – Electronic Claim Submission
– Joint Venture Partnerships
• Care Coordination
– Member Connections
– Co-Location Provider Offices and FQHC
– Case Management
• State Partnerships
– Participate with other MCOs and State
If you can run the
company a bit more
collaboratively, you get
a better result, because
you have more
bandwidth and
checking and balancing
going on.
Larry Page, co-founder
of Google
Program Integrity - Results
Centelligence™
Stopping Shopping
for Narcotics
System edits decreased trends in doctor shopping trends
for this group of patients at 6 months:
 95% decrease in South Carolina
 80% decrease in Ohio
 90% decrease in Florida
 98% decrease in Georgia
We identified an Ophthalmologist consistently billing
procedures on five consecutive days to enrollees that
lived in the same apartment complex.
Review of the records indicated significant concern
and the case was referred to the MFCU.
EMPLOYEE
EDUCATION
An employee reported concerns
that a home health agency may
have been billing for services that
the Foster Parent was providing to
their Foster Child. A record review
validated the allegation and
identified a potential
overpayment of $1.3 million.
The provider was reported to OIG
for potential fraud.