How to Add Value to Your Program Integrity Initiative
August 08, 2023 by Robert M. Finlayson III
In November 2022, the Centers for Medicare & Medicaid Services (CMS) estimated that 15.62% of all federal Medicaid expenditures, a total of $80.57 billion, were improper payments — payments that “did not meet statutory, regulatory, administrative, or other legally applicable requirements.” This represents a substantial increase over reports in 2019, in which CMS estimated that $57 billion or 14.9% of all federal Medicaid expenditures were improper. In 2020, COVID-19 put unprecedented pressure on Medicaid agencies as more people became eligible and agencies relaxed regulatory requirements to address a very real public health crisis. With Medicaid agencies under intense pressure to provide immediate necessary relief to members and providers, state program integrity operations faced one of the most challenging times in history to protect their programs.
To try to combat improper payments, federal regulations require all states, the District of Columbia, and all U.S. territories to have a program integrity operation in place within their Medicaid programs. Recent regulations also require Medicaid Managed Care Organizations (MCO) to beef up their program integrity operations to perform more like the states. Further, CMS requires states to modernize their Medicaid Management Information Systems (MMIS) into a modular approach — now called the Medicaid Enterprise System (MES) — with an emphasis on best in breed technology in each module. CMS has identified fifteen checklists that are applicable to the modules within the MES, one of which is program integrity.
The Problem With Program Integrity Solutions
As Medicaid agencies implement and upgrade their systems to meet these requirements, it is critical that they pay special attention to their program integrity functionality. In the past, program integrity solutions have focused on Medicaid claims analysis within their Surveillance and Utilization Review (SUR) and Fraud and Abuse Detection (FAD) subsystems. This involves big data analysis of millions of Medicaid claims in an effort to identify aberrancies that may indicate an improper payment or poor quality of care. The failing of these solutions, in addition to not having sufficient analytic power to correctly identify aberrancies in the data, is that they lack any meaningful case management and automated workflow to effectively investigate the aberrancies that are identified.
The Case Management Alternative
Recent requests for information and proposals by states, however, have specifically requested more information about case management. State leaders overseeing program integrity have recognized the lack of functionality in their solutions and are looking to the technology market to see what it can offer.
Moving forward, case management must not only help the state meet federal regulation requirements, but also provide a meaningful solution that will add true value to their operations. Case management solutions must be configured to meet the requirements of 42 CFR 455 and 456 including:
1. Methods and criteria for identifying suspected fraud cases
2. Methods for investigating these cases that:
a) Do not infringe on the legal rights of persons involved
b) Afford due process of law
c) Include procedures, developed in cooperation with state legal authorities, for referring suspected fraud cases to law enforcement officials
d) Conduct “preliminary investigation” if the agency receives a complaint of Medicaid fraud or abuse from any source or identifies any questionable practices
e) If fraud (or abuse) is suspected, refer to the Medicaid Fraud Control Unit for “full investigation”
3. Safeguards against unnecessary or inappropriate use of Medicaid services and against excess payments
4. Assessments of the quality of those services through review of services provided
5. Provisions for the control of the utilization of all services provided
Key Program Integrity Functions
In order to meet these criteria, case management platforms must seamlessly integrate with powerful healthcare analytics platforms to enable clean, easy-to-use workflows between three key functions: identification, investigation, and adjudication.
Identification: Powerful, state-of-the-art health care analytics platforms provide the tools necessary for the program integrity team to identify improper payments in both post-pay and pre-pay scenarios. These platforms also can perform continuous eligibility analytics to constantly ensure that only eligible recipients receive benefits and only eligible providers are paid. Effective platforms limit false positives, dive deep into multiple data sources, and correctly identify leads for investigations and review teams to follow up on.
Investigation: Once a lead is identified, there must be a clean handoff to effective case management to “take it from here.” Without this key component, a bunch of leads is just the “dog who’s finally caught the fire truck!” Now what?
Effective case management must be able to deal with a broad spectrum of investigative processes including case intake, decision to investigate, case assignment, intake of evidence, process tracking, referral to another authority, and reporting. It must be continuously configurable to allow for the ever-changing environment of agency, regulatory, and statutory business requirements and to be easily modified within the solution’s business processes. This is a tall order considering the rate at which state legislative mandates and federal regulations change.
Finally, the case management solution needs to allow for a clean and easy handoff to the final function, adjudication.
Adjudication: Even the best fraud identification and investigation procedures must have effective adjudications in order to win. In all my years of working in the program integrity field, I never encountered a provider that just gave up and wrote a check when we sent him a demand letter (unless we undervalued the recovery)!
Case management platforms must be able to deal with the final aspects of any case: appeals, recovery, and closure. While every adjudication process is different, they are all driven by specific events, and they rely on accurate collection of important data. Every case for adjudication includes a respondent, an issue or problem that requires resolution, and a basis or guideline against which any appeal is made. Case management platforms must be configurable to support all types of adjudication processes and specific agency, regulatory, and operations business requirements.
Don’t settle for a solution that doesn’t make your life easier throughout your operation. In reviewing your options, make sure that whatever solution you consider adds real value to each of the critical areas: identification, investigation, and adjudication. Effective case management is one way to integrate each area and help protect your program.
Robert M. Finlayson III is a Senior Business Development Executive for Tyler. Formerly the Inspector General for the Georgia Department of Community Health, he has 33 years of experience in the investigation and administration of federal and state public assistance programs.