Medicaid Claims And Healthcare Waste: While The Data Flows, New Cracks Surface

With the heightened attention that commentators and government administrators have paid to the need for precise claims data in federal health care systems, one might have hoped that presently, approximately 2 years later, the issues would be tended to and the federal government's data rendered more dependable. Unfortunately, while improvements may well have been made, gaps in the programs continuously surface. Merely a couple of weeks ago, the Department of Health and Human Service's Office of the Inspector General ("HHS-OIG") published a report concerning flaws in the "Medicaid Interstate Match" program, which is aimed to minimize improper Medicaid payments by identifying beneficiaries that are registered in the Medicaid programs of more than one state. Despite the fact that the document does not directly suggest that issues in the Medicaid Interstate Match program are going to consequently impair fraud investigations or even result in the targeting of innocent Medicaid participants, it nevertheless again draws attention to the fundamental problems that exist in depending on data mining in the federal government health care system.

As the report from the HHS-OIG specifies, the Medicaid Interstate Match belongs to a more comprehensive data gathering program (the so-called "Public Assistant Reporting Information System," or "PARIS") that makes use of Medicaid enrollment records so as to determine if the very same person is acquiring government health care benefits from more than a single source or from more than just one state. The Medicaid Interstate Match in particular can identify cases in which patients continue to be enrolled in a given state's Medicaid program in spite of the fact that they have relocated to a different state and are receiving benefits from that second state's Medicaid program. Despite the fact that a person's receipt of money from more than one state's Medicaid program frequently results from a failure to promptly report a change of address, as opposed to from an intent to defraud, the program could nonetheless spare the Medicaid program significant amounts of funds that recipients are not eligibled to receive. Consequently, as of October 1, 2009, the Social Security Act mandated every state to participate in the Medicaid Interstate Match, and the Centers for Medicare and Medicaid Services ("CMS") oversees the issuing guidance involving such involvement.

Read more at: http://www.syrtissolutions.com/medicaid/9355

Nevertheless, as the HHS-OIG uncovered in its report, the engagement of the various states in the Medicaid Interstate Match program is considerably limited. Indeed, of the 4 measures that HHS-OIG has identified as constituting "participation" in the Medicaid Interstate Match (notably, CMS has not on its own previously described the term "participation," even though such participation is a pre-requisite with regard to securing federal funding), some of these measures in fact are not taken. As an example, while state involvement in the Medicaid Interstate Match requires that a state submit its enrollment data so that records can be matched with that from all other states, HHS-OIG determined that, for a sample 3 month period (the Medicaid Interstate Match administered on a quarterly basis), fourteen states did not provide Medicaid enrollment files for each of their enrollees, and with regard to those 14 states, on average merely 46 percent of the relevant data was supplied. As another illustration, in order for the Medicaid Interstate Match program to perform a significant role in discovering improper benefits payments, information that seems to signify a match among beneficiaries in more than just one state must be validated, in order to substantiate that there is not a "false positive." Nevertheless, the HHS-OIG report established that the states did not verify almost 70 percent of the matches that were identified, in part because the enrollment information submitted by the states was incomplete. Because of these and other problems, the HHS-OIG report reveals that for the three-month time frame under examination, not a sole improper Medicaid payment was recuperated by means of the use of the Medicaid Interstate Match.

Exactly what is one to make of HHS-OIG's document relating to the failings of the Medicaid Interstate Match? Initially, there is the somewhat anti-climactic or even clear determination reached by HHS-OIG, which is that "CMS should issue guidance to states on the requirement for participating in the Medicaid Interstate Match." Wisely, perhaps, CMS "concurred" with this guidance.

More vital, though, are a couple of observations which could be of particular relevance to those who practice in the healthcare fraud sector. First and foremost, HHS-OIG details in its document that, according to CMS, "5.8% of all Medicaid payments made in fiscal year 2013 were improper, representing $14.4 billion in Federal expenditures." The federal government frequently specifies such substantial numbers as evidence of widespread fraud, waste, and abuse that supposedly exists in federal government healthcare programs. Yet in point of fact, the HHS-OIG report offers some much needed context, indicating that 57% of the "improper" Medicaid payments come from more prosaic, mundane issues, like the "eligibility errors" that arise when a person moves from one state to another and doesn't supply Medicaid with a change of address. Fraud in the Medicaid program may still be a dramatic problem, but when "improper payments" are the outcome of these kinds of "eligibility errors" instead of fraud, the true extent of the challenge can better be recognized.

Second, despite the fact that the Medicaid Interstate Match is meant to detect eligibility mistakes rather than fraud, the defects in the gathering and utilization of Medicaid records continue to reinforce significant concerns. As this blog has noted, dependence on unreliable data and flawed methodology can lead to innocent participants in the healthcare system being exposed to expensive, lengthy, and potentially crippling audits and investigations. Additionally, while initiatives to correct data inaccuracies and address issues in program implementation might sometimes have a beneficial effect, systemic problems relating to the overall size of the Medicare and Medicaid programs, the nature of the bureaucracies which surround them, as well as the challenge of coordinating federal-state interactions in such a complicated area might render it impossible for healthcare data mining to ever be a fully reliable source of investigative decisions. For the regulatory authorities, auditors, investigators, and prosecutors who rely upon government data when determining whether or not to bring their power to bear on individuals who are the subjects of costly and burdensome health-care investigations, every one of these issues must carefully be weighed in the mix.

Why "Pay and Chase" when your business can cost avoid?

It's certainly not easy to identify primary business insurance coverage with regards to your plan's members at the point of sale-- costing your company time and money tracking down reimbursements for claims that others should certainly have paid for. And thus far with little luck: generally no more than 17 % of the money billed to primary insurance carriers is actually recovered through Medicaid plans that paid off claims in error.

Why spend for additional health plan data your business simply cannot utilize? ProTPL provides prompt intelligence you will be able to act upon-- not a mass of information and facts.

As soon as ProTPL finds additional medical insurance, you can reverse the most recent claim and ensure that future claims, whether pharmacy and medical, aren't paid in error. Identifying additional medical insurance swiftly, prompted by means of Pharmacy claims, permits your company to intercept the medical claims, which include office or ER visits, that practically always follow upon a pharmacy claim. The moment those new claims turn up, high quality eligibility details cross-walked between pharmacy and medical alleviate the necessity for "pay and chase.".

ProTPL immediately identifies commercial insurance coverage that other vendors are normally not able to discover. Our users see an average 25 % boost in various other health insurance identification. Your claims are actually checked against a master patient list of over 280 million commercially covered lives; the pay and chase biggest and most complete data source connected with active health care policy coverage information in the country. This means you get the best as well as latest eligibility responses the moment you need them--sparing you the expense of recovery.

http://syrtissolutions.com/third-party-liability/pay-chase-can-cost-avoid/

The Demand for Syrtis Solutions' Cost Avoidance Program

In 2006, the United States Government Accountability Office (GAO) released a statement to the Centers for Medicare and Medicaid Services (CMS) on the problems faced by states in putting into effect Medicaid third-party liability (TPL) prerequisites.

The record cited two basic problems:
The challenge concerning confirming Medicaid beneficiaries' private health coverage because of the absence of trustworthy data sources. In the absence of reliable data, approximately 13% of all Medicaid recipients that use unreported primary health policies are actually costing states billions of dollars annually in healthcare expenses that ought to be paid for by a third party.
The issue inherent with the collection of costs from third parties. Retroactive recovery procedures, often regarded as "pay and chase," are really costly, ineffective as well as only able to yield 17% for each dollar wrongly spent.

In an effort to address the issues described in the GAO report, CMS issued guidance to states in a 2008 Budget Brief that requires states to uphold the cost avoidance criterion for pharmacy claims as well as do away with waivers that authorize pay and chase approaches.

Built upon this particular guidance, states have indeed reacted by establishing coordination of benefits (COB) programs which count on self-reported recipient eligibility data and/or on stagnant data accumulated by TPL vendors for pay and chase purposes. That information is definitely incomplete, latent and certainly not sufficient for true cost avoidance. If you want to successfully satisfy CMS' cost avoidance guidelines, a reliable point of sale approach that accesses a real-time nationwide data bank of health care coverage would be called for to cost avoid claims and eradicate the problems attempting to collect monies for claims that states should have not paid to begin with.

In 2008, on behalf of disaster relief initiatives, CMS relied on Syrtis Solutions to deploy a real-time pharmacy cost avoidance solution at the point of service (POS) following hurricanes Ike and Gustav. CMS needed a service that would prospectively cost-avoid pharmacy claims especially for those patients with other health coverage. The solution accessed Surescripts' Master Patient Index (MPI), which houses in excess of 230 million lives, to prospectively identify individuals having other health coverage at the point of sale.

The Emergency Prescription Assistance Program (EPAP) was a success, cost avoiding 15% of all claims in sub-second transaction times with zero timeout issues and, most importantly, without involving workflow adjustments at pharmacies.

Cost Avoidance Case Study for Medicaid Payers - Syrtis Solutions

In a one year case study with a Medicaid plan, we found that, on average, 1.3% of utilizing members where identified as having other insurance. In other words, Syrtis processed nearly 3 million pharmacy claims and returned approximately 38,000 members identified with other primary insurance. This lead to an estimated annual pharmacy claim cost avoidance of $15 million dollars. Find Out More

Strategic Actions to Curtail Medicaid Fraud

Medicare's swelling price tag might be reined in. Here are the steps taken and future actions required to restrain Medicare fraud, according to the GAO.

Enhance Provider Application Requirements
The GAO has discovered continual weak areas in the methodology employed by the Centers for Medicare & Medicaid Services (CMS), the national department that supervises Medicare and Medicaid, to register Medicare service providers. If enrollment approaches were actually bolstered, potential fraudulence could be impeded.

For instance, in early 2011, CMS established a restricted, moderate and high standard of risk for providers and established varying screening measures for each classification. However, the GAO uncovered that CMS had not performed the following actions, as stipulated by the Patient Protection and Affordable Care Act (PPACA):.

• Establish core elements with regard to compliance programs for providers.
• Disperse a regulation demanding extra provider info.
• Create background checks hinged on finger prints.
• Specify which providers would be obliged to post surety bonds, and that consequently, should ensure the recovery of falsified claims.

http://syrtissolutions.com/medicaid/critical-steps-curtail-medicaid-fraud/

Regulation Could Reduce Medicaid Abuse, Waste and Fraud

The Government Accountability Office (GAO), the guard dog for the U.S. Congress, verified that Medicaid and Medicare are programs having potential for a higher risk of abuse, waste and fraud. In the case of Medicaid, the GAO suggests substandard fiscal management might lead to improper expenses. A complex Medicare system could easily result in erroneous disbursements.

The Centers for Medicare & Medicaid Services (CMS), the Department of Health and Human Services (HHS) that supervises these programs, concluded that in 2010 that over $70 billion dollars was paid out improperly. Simply by administering past GAO proposals, recently passed legislation and existing agency courses of action, the CMS could accomplish five approaches presently detailed by the GAO as approaches to decrease inappropriate Medicaid and Medicare payments, and thus helping reduce fraud.

Sustain Five Areas to Fight Medicaid and Medicare Abuse