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

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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
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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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Indianas Systematic Approach to Combating
Improper Payments
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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
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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 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

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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

• 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

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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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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