Data for Medicaid Program Integrity

Tyler Podcast Episode 29, Transcript

Our Tyler Technologies podcast explores a wide range of complex, timely, and important issues facing communities and the public sector. Expect approachable tech talk mixed with insights from subject matter experts and a bit of fun. Host and Content Marketing Director Jeff Harrell – and other guest hosts – highlights the people, places, and technology making a difference. Give us listen today and subscribe.

Episode Summary:

Like so many, Medicaid agencies were forced to change the way they do business due to the pandemic. While serving Medicaid recipients remained the top priority, new opportunities for fraud made program integrity a more urgent focus than ever before.

In this fascinating episode, we talk with Jason Helmandollar, vice president of Healthcare Solutions at Pulselight, and a nationally recognized expert on Medicaid fraud. He walks us through the changes in Medicaid brought on by the pandemic, the opportunity those changes opened up for fraud, and how the individuals responsible for program integrity can use data to help ensure the right people are getting the services they need.

Transcript:

Jason Helmandollar: I'm working a case, and I've got a question that's always going to involve data if I'm talking about Medicaid. Instead of me having to write a ticket and give it to that analyst who puts it in their queue of ten other requests and they get to it when they can, and then they get you a result and it's not exactly what I wanted and now I have to go back, instead of all of that, let that investigator go in and explore themselves, look at complex behaviors without having to have the skillsets that an analyst does. It can drastically accelerate and broaden the things that you're looking at and looking for.

Jeff Harrell: From Tyler Technologies, it's the Tyler Tech Podcast, where we talk about issues facing communities today and how are the people, places, and technology, making a difference. I'm Jeff Harrell, I'm your host and the director of content marketing here at Tyler and I'm so glad that you joined me. Well, the pandemic certainly impacted everyone in one way or another. We've all had to pivot in some way. I'm certainly not needing to convince you of that, but there are areas of government and in this case specifically, healthcare that didn't have to pivot, they actually had to completely revamp the way that they serve their constituents. One area in particular was Medicaid. How do you get services to people during a pandemic? And how do you keep the integrity of the program when there's bad actors out there trying to take advantage of the current situation? Well, to help us unpack this is Jason Helmandollar.

Jeff Harrell: Jason is the vice president of healthcare solutions at Pulselight. Now Pulselight is a software company serving the healthcare industry by providing fully hosted web-based analytics solutions designed to address the most urgent challenges facing healthcare payers today. In his role, Jason is responsible for driving the development of analysis techniques and investigation skills. He's an expert on Medicare fraud having served as a special agent supervisor with Ohio's Medicaid Fraud Control Unit. Jason has investigated to help prosecute hundreds of fraud cases and was instrumental in developing new data analysis techniques and drove the recovery of billions of dollars for Ohio and other states, I have to ask him about that one.

Jeff Harrell: He's going to help us shed some light on this very important and complex problem. So without further ado, here's my conversation with Jason Helmandollar.

Jeff Harrell: Well, Jason, thanks for joining the Tyler Tech Podcast. Excited to have you.

Jason Helmandollar: Thank you. Appreciate it.

Jeff Harrell: And I wanted to dive first of all, because I read your bio and I want to clarify something here. It says in your bio that you helped save billions of dollars. I really wanted to ask, how did that happen?

Jason Helmandollar: I get that pretty often actually. It is an accurate statement. So in my former career, I worked for the Ohio Medicaid Fraud Control Unit. For the last eight years of the time that I was there I worked for a national organization called the National Association of Medicaid Fraud Control Units. And they worked quite a bit with the federal government on national drug pharmaceutical cases and settlements. These were usually whistleblower cases that the federal government had intervened, and they involved both Medicare and Medicaid funds.

Jason Helmandollar: So my role working on those cases was basically data analysis. I would determine damage models. So based on whatever the alleged behavior was, I would figure out how much money was lost on the Medicaid side, and I would do that by gathering data from all the other states and analyzing it. And then once the settlement was reached, it was my job to figure out equitable allocation of the funds across the state. So those cases, as you can imagine were pretty huge. For example, one of the ones I worked on towards the end of my career, there was a Pfizer settlement that was $2.3 billion, just that one settlement. So I was very privileged to be able to work on those cases.

Jeff Harrell: Today we're talking about Medicaid in Medicaid fraud, and I thought we could just start, if you would just define what is Medicaid? When we're talking about Medicaid, what is that?

The Difference Between Medicare and Medicaid

Jason Helmandollar: Yeah, sure. A lot of people get Medicare and Medicaid confused. Medicare is generally for your older population. Also a lot of times people with disabilities and things are also on Medicare. Medicare is administered by the federal government. Medicaid is typically lower income individuals within states along with a lot of other situations that can cause you to be eligible for Medicaid. And it is administered by the states. It's a partially federally funded program, but each state administers their own Medicaid program. And basically it is a healthcare system. It's a way for individuals who are on Medicaid, we call them recipients, can receive medical services and supplies, and other things that they need. And it's through that program that they're able to do so.

Jeff Harrell: So that's great. And I know that the pandemic has caused all of us to pivot in one way or another. And I imagine that the Medicaid system had to pivot quite a bit as well with COVID-19. What are some ways that the Medicaid system had to do that?

Jason Helmandollar: Pivot is a very soft term for what actually happened I think. If you go back in time a year or so to, well, the beginning of 2020, first of all, we didn't even know we were all blissfully ignorant about what was to come, around February, I think is when we first started hearing rumblings of the coronavirus. And I believe the disease wasn't even named until February, March, but at that point that's when things really accelerated and it wasn't just a pivot, it was full on damage control, it was, it was emergency mode for every state, every Medicaid program. And the reason for that is suddenly everyone needed to stay inside. So what we saw was a very dramatic decline in the services that people were receiving through Medicaid. And I'm sure that same trend was seen across all insurance and just medical services in general during that timeframe.

Jason Helmandollar: People were staying at home; providers were shutting their doors and I'm going to use the term provider a lot. When I say provider, these are the people who provide these services. So doctors, dentists, ambulance companies, medical supply companies, laboratories, those are all referred to as providers in the Medicaid and Medicare programs. So providers were shutting their doors and we just saw this huge decline in the actual services that were occurring. That was the reason for concern. And it's mainly because the fear was people who needed care weren't getting it.

Jeff Harrell: Jason, with that impact, how did Medicaid change in response to this lack of providers being able to give the services they normally do?

Jason Helmandollar: Mainly it was around relaxation of policies. So the states reacted in the way that they had to, which was they needed to do what they could to try to make sure that people had access to the care that they needed. So it was really three things. There was a relaxation in enrollment requirements. So when a provider wants to start doing services for Medicaid, they have to go through an enrollment process. And there's a lot of different checks and things that go into that. The policy surrounding that were relaxed. The idea was let's bring in more providers; therefore, we'll have more of them out there to provide services. Secondly, there was a relaxation in the billing policies themselves. So Medicaid is full of rules and regulations and policies that dictate the way that providers can bill for services. Some of it is just around equity and things like that, but also some of it is around trying to prevent overpayments, waste, abuse, and fraud.

Jason Helmandollar: So a lot of those policies were relaxed. So it was, let's bring in more providers and let's make it easier for them to bill for the services that they need to provide. And that leads into the third thing, which is the rise of telehealth. So in order for these providers to do some of these services that they had done in the past during the beginning of the pandemic, it needed to be done remotely. So while telehealth is something that's been around for a very long time, it was actually used relatively rarely, starting in about March of, 2020, it became the primary way, I would say, that a lot of different services were provided in the Medicaid program. And what came along with that was a lot of confusion.

Jeff Harrell: Well, I like what you said that the states did what they had to do to care for their constituents, but I would imagine, unfortunately there's bad actors out there when I hear relaxation of policies, I would imagine that invited some fraud and other things as you just refer to. So what was the impact on some of those things as a result of relaxation of policies?

Jason Helmandollar: It was a perfect storm for fraud I would say. You're relaxing who can become a provider in your program, you're relaxing the way that they can bill, and then you are creating alternate methods for them to bill that frankly have fewer eyes on it. It's harder to see what happened in a telehealth service and then an in-person service where two people are standing there looking at each other. So it definitely was a perfect storm. To talk about what happened, let me break it down into categories. So let's go with enrollment fraud first. So when you relax the policies around provider's ability to enroll in Medicaid, what happens is you have nefarious providers coming out of the woodwork. There are a lot of reasons why you can't enroll in Medicaid and many of them are around prior convictions of some sort of a fraudulent activity or even association with individuals who've been convicted of fraud.

Jason Helmandollar: So what happens is if someone who it's in their nature to commit fraud gets in trouble and now they are excluded from the Medicaid program, usually Medicare as well, then maybe we don't hear from them for a while, but if you start relaxing policies or what you're doing is trying to enroll people as quickly as possible so not doing the checks that are necessary, suddenly those people see an opportunity and you might see some in newly enrolled providers that really shouldn't be allowed to be enrolled.

Why "Fraudsters" Seized This Opportunity

Jason Helmandollar: So that was one category. In terms of general billing fraud, when the pandemic struck, so we're talking about, let's say March of 2020, as I mentioned there was this drastic decline in most services. So the way that nefarious individuals, I'm going to refer to them as fraudster and I don't feel bad about that because I'm specifically talking about here people who that is their life's mission is to commit fraud and to get funds that they don't deserve. So we'll call them fraudsters, again, they saw this as an opportunity where everyone's looking the other way, everyone's concerned about what's going on with the pandemic, they want to make sure that people are getting the services they need. So necessarily the way that they were looking for fraud was altered, reduced if you will.

Jason Helmandollar: So we start seeing a lot of people billing for services not rendered, unnecessary services. With telehealth, again, there was this general confusion because telehealth came on so quickly, there were new codes being created, new procedure codes these are the things that these providers actually build to get paid that says, "Here's what I did." There were new modifiers, a modifier is something else you put on a claim to say, "Well, this was a telehealth service," or something of that nature.

Jason Helmandollar: It's usually just a number you put on there. So all of these new things were coming into place, and everyone was sort of confused about how to implement them and in that environment it's easy for someone who wants to commit fraud. And let me be clear about what I mean by fraud. Fraud is when someone intentionally does something in order to get paid money that they shouldn't basically. If someone mistakenly builds the wrong code or in the wrong way, that's not fraud, that's waste, it's an overpayment, it's something of that nature. But what could happen was everyone was confused about how to bill for telehealth. So it was the perfect place for these fraudsters to come in and not only bill for things that they shouldn't have, but even if they were caught, all they had to do was say, "I didn't understand these new rules and therefore, not face the consequences of fraud itself."

Jason Helmandollar: We saw the emergence of this thing called audio only code. So then you run into a technology problem where normally telehealth is supposed to be, I am doing a FaceTime with someone, I can see them on the screen and I'm talking to them and they're showing me where it hurts and that sort of thing. What happens when the patients don't have the technology to do that? Well, then we saw the emergence of audio only codes, which is a telephone call. Should an audio only code service be paid the same amount as a regular telehealth service or an in-person service when basically all you can do is talk to them on the phone? A lot of confusion around that. We saw telehealth approved for illogical services, physical therapy, how do you give someone physical therapy over the telephone? But with that said, there are people out there who need physical therapy, who may not be able to go and have it done in person.

Jason Helmandollar: So there were just a lot of concessions made in order to make sure that people were getting the care they needed, and definitely a lot of places for certain providers to come in and take advantage of that. Another example is there's a system in place called EVV, Electronic Visit Verification. This is a way for you to make sure that personal care assistance, home health aids are actually showing up at the home to take care of someone. So they use GPS and other devices to check on them and make sure they're there. Well, there was also a relaxation of EVV rules at this time. We saw people taking advantage of that. And then of course there was a rise and kickback schemes, there was a rise in laboratory fraud. We've heard all sorts of stories about lab testing that had to do with COVID-19, genetic lab testing, all sorts of fraudulent schemes going on around that.

Jason Helmandollar: We've been working on something that has to do with confirmation testing in labs. This is where if someone comes in to get a drug screen which is a panel of tests for a variety of drugs, and in the result of that is a yes or no, yes, you were positive for one of these drugs or, no, you weren't. If the answer is yes, then you can do a follow-up billing, which is called a confirmation test and this test then allows you to figure out which of the ten drugs that this panel tested for were you positive in? So they were positive for cocaine, for example. Well, we're seeing labs that are billing a confirmation test, along with the drug panel, 98% of the time, that means if it's happening the way it should, 98% of the time that someone takes a drug test, they're testing positive. I don't believe that's true. So there's just one scheme after another just seems to be popping up and it's really a result of everyone necessarily looking the other way.

Jeff Harrell: So, Jason, I want to talk a little bit in a second about some of the solutions to this fraud problem, but before we leave the pandemic, I just wonder if were there any other health-related consequences that you saw from the pandemic?

Jason Helmandollar: Yes. Unfortunately, one of the things that we've seen that's most disturbing is a restrengthening or a re-emergence of the opioid crisis. So if people will remember, before the pandemic we had another national epidemic and that was opioid utilization and overdose. We were doing quite a bit of work in that arena. Prior to the pandemic, what we saw was states were strengthening their rules around the amounts of opioids that a doctor or other could prescribe. They were strengthening rules around the potency of those drugs, and they were enforcing it much more. So what you saw was a general decline in the amount of opioids that was being prescribed in the Medicaid program and the strength of those opioids, and a general decline in the number of overdoses that were occurring as a result of prescription opioids. Now, unfortunately, the flip side to that, and one thing we've learned is that there are always consequences to everything is we were seeing a rise in the number of heroin overdoses that were occurring.

Rise of Opioids During the Pandemic

Jason Helmandollar: So of course, when your doctor will no longer prescribe to you the opioids that you need, and you have a use disorder, one option is to turn to the street basically and buy heroin. So we were seeing that disturbing trend. What's happened since the pandemic is actually a reversal of that. And now opioid prescription overdoses are on the rise. Doctors are prescribing opioids more now, people are taking more opioids now since the pandemic, and they're overdosing on prescription opioids, and actually heroin overdoses has declined. It's a disturbing trend in the opposite direction, but this is in a sense, a reversal of something that we've worked years to try to reverse, which is the over-prescription of opioids. And that's probably the most disturbing thing that we've seen since it started the pandemic.

Jeff Harrell: And are doctors prescribing more because of the pandemic, they're getting more cases of depression and things because of the isolation?

 

Jason Helmandollar: I believe that has something to do with it. I think it plays a huge part as a matter of fact. Anyone who has any type of addiction, I would imagine that the last year, year and a half have been really tough for them to try to maintain sobriety in whatever way that they try to maintain that. So that of course is going to play a role. And we're seeing large spikes in other types of drug prescribing activity as well, such as anti-anxiety, and anti-depression, and psychoactives and things like that. So definitely there is a mental health issue that goes right along with this, and maybe just as important in this country since the onset of the pandemic. So I do believe that that plays a role. I think the other thing that plays a role is, again, no one's looking at the prescription activity of these doctors in the way that they were pre pandemic in terms of opioids. So they feel like they can, some of these individuals who are prescribing these drugs feel like they can in a way get away with it right now.

Jeff Harrell: Well, let's jump back into what you're describing earlier around the fraudsters and some of the things going on with Medicaid. Tell me a little bit about the role of program integrity and how that can help address some of these issues.

Jason Helmandollar: So when we, when we talk about program integrity and in Medicaid, it's usually an agency, it's a department. So as I mentioned, Medicaid is state administered. So in every state, there is an agency that is many times referred to as the single state agency or just the Medicaid agency. But this is the government agency that administers the Medicaid program. It's their job to adjudicate claims, pay those claims, do everything that needs to be done for the Medicaid program to work. A sub part of that would be program integrity, which is we are ensuring the integrity of the Medicaid program. So that can mean a lot of different things. It can mean we want to make sure that we're paying the right amount for certain things and all that. But many times you'll see program integrity focusing in on what we call fraud waste and abuse.

Jason Helmandollar: So of course, fraud, criminal fraud, waste would be the other end of that spectrum where this is money that we're paying out that we don't really need to, it's not necessary for what's going on. There are ways that we could not pay this money toward services. And then abuse is sort of in the middle. You can have someone who's abusing existing policies to get paid for certain things, but it doesn't rise to the level of criminal fraud. It might just rise to the level of, this is a policy we need to change so that people can no longer abuse it legitimately. So these program integrity units within the single state agencies, it's their job to identify when these types of things are going on, to investigate instances of potential fraud waste and abuse, to perform audits on providers, to check up on what they're doing versus their documentation.

Jason Helmandollar: And a lot of times they're referring it out to other agencies. So the Medicaid Fraud Control Unit that I worked for, we received referrals from the program integrity unit when they would uncover something that seemed to rise to the level of criminal fraud, and then ultimately to try to prevent it from happening in the future. And many times that is by suggesting changes in policies or new edits, which would be standard check that's done on claims that as they come in to make sure that whatever this behavior was that we found is no longer occurs in the Medicaid program.

Jeff Harrell: So Jason, I mentioned there's lots of cases, lots of claims coming and going, how do you identify where the problems are? How do you solve this problem?

Jason Helmandollar: Data's the key. As claims are submitted by providers, as they're adjudicated by the state and meaning the decision is made whether to pay it, whether to deny it, when payments are made, that can all be brought together to form behaviors. So when you go looking for fraud waste and abuse in the Medicaid program, there's a couple of ways you can go about it. One would be at the claim level. So a claim is submitted that has 100 different components to it. What was done? What was the diagnosis? What were the modifiers? Where was the place of service? Where did it occur? All of these things can come together even on a claim-by-claim basis, or even a service by service basis. You can make some determinations to say, "Oh, we shouldn't pay this. This is against our policies," or something like that.

Jason Helmandollar: Normally though, those would not even fall into the realm of at least fraud and abuse. When you start looking for those types of things, it becomes less about an individual claim and more about the behavior of an individual or a company. So at Pulselight, we talk a lot about behavioral analytics and it's the idea of, we want to take a behavior, or we want to identify a behavior and we want to help to investigate that behavior in order to get to a point where there's evidentiary material to move forward, whether that's a recovery or full-blown criminal investigation or whatever it may be. So what states need to do, and they do this to whatever extent they're capable of is to leverage the technologies that are available today because at their fingertips is everything they need in terms of information to identify these behaviors.

Jason Helmandollar: It's just a massive amount of data. There are, I don't know how many claims in an average state are submitted every day, but I can tell you it's millions and millions and millions of claims are submitted on an annual basis across the different Medicaid programs. So this becomes this almost unmanageable dataset. And how do you go about discovering the situations that need to be pursued? And so if we look at some of the legacy program integrity tools, a lot of times what you would see are what can be boiled down to save queries. A lot of times they're referred to as algorithms. So these are established well-known behaviors that providers commit that are suspicious, and they have been coded in such a way that you can run this query against your data warehouse. This is where all of the data from Medicaid services is stored and get reports back to tell you what's going on.

Jason Helmandollar: I call these legacy because this is sort of the established way that things have been done for many, many, many years. The problems with it are, number one, you're starting from well-known established behavior. So that's what was coded and that's what you're looking at when you run this report, say, once a month or something like that. What it doesn't account for and what it can't help you with are new and emerging schemes. When we talk about fraudsters, I'll just go on a little tangent here, as a criminal investigator, one of the most important things to do is you have to put yourself in the mindset of someone who's committing the crime. So when you think about these individuals that are perpetrating fraud and healthcare programs, these are smart individuals, and they understand the system and they've figured out ways to get around it.

How "Fraudsters" Take Advantage of the System

Jason Helmandollar: And if a roadblock pops up, a new policy or something of that nature, they don't just stop, they figure out a way around it. They change their behavior in order to continue going. These are people who have bills to pay just like everyone else and if they want to buy that new boat or something, they've got to figure out how to keep that income coming in. So these are the individuals that we're dealing with. So when you think of these legacy systems, and it's just, "I have a library of 500 queries that you can run every month," then what happens is things get stale, people go around your queries in terms of their behaviors, and you have a problem. So newer technologies you could, say, use something that we refer to as data analytics. So what does that mean? The word analytics is thrown around all the time, all over the place in my mind.

Jason Helmandollar: And analytic is very different from an analysis. So let's say that I suspect that a provider is committing fraud in X way then I might say, "let's do a project and we're going to perform an analysis and in order to do that, I'm going to have an analyst go in and write some queries and produce some spreadsheets and then we'll go through all those and try to get to some sort of a result." That's an analysis project. And analytic is an actual construct of technology that you can access. Think of it as a tool where now you can go in and not only access that behavior instantly, but explore it and repeat that over and over again and reconfigure it on the fly as you go. So if you think, "Oh, wait, providers might be just tweaking this a little bit in order to get around this new policy, it's very easy to adjust your exploration and move in a different direction."

Jason Helmandollar: And then you can memorialize it that way. So you very quickly pivoted to a new behavior and that's something that you can always be checking for in the future, as you continue to continue pivoting as the fraudsters do as well. So what this does is it drastically accelerates the program integrity's units, their units, their ability to address fraud waste and abuse in the Medicaid program, but in a very nimble way, in a fast way, and also taking advantage of the skillsets of everyone on your staff.

Jason Helmandollar: There's a thing that I call the analyst bottleneck, where I'm an investigator, I don't know how to go and query in SQL or write code or something like that, but I'm working a case and I've got a question that's always going to involve data if I'm talking about Medicaid, instead of me having to write a ticket and give it to that analyst who puts it in their queue of ten other requests and they get to it when they can, and then they get you a result and it's not exactly what I wanted and now I have to go back, instead of all of that, let that investigator go in and explore themselves, look at complex behaviors without having to have the skill sets that an analyst does, it can drastically accelerate and broaden to the things that you're looking at and looking for in the realm of fraud waste, and abuse.

Jason Helmandollar: So the idea of data analytics can get you around this bottleneck, it can accelerate the things that you're doing, it can allow you to leverage other data sources, which again can be difficult to do when you just have an established query that only looks at your Medicaid claims. Well, what about if we go back to the provider enrollment issue where providers who may have prior convictions or issues with enrollment are starting to enroll again. Well, the ways that you can check for that are there are lists out, there exclusion lists, you can get data from your state licensing boards to see has this provider gotten in trouble with the licensing board.

Jason Helmandollar: These are all pieces of data that currently are somewhat siloed, and you can bring those altogether and leverage them within an analytic environment, again, without having to do a project, a two week project in order to do it. So that's what's necessary to move forward, to be fast, to be nimble, to be responsive to the changing environment as the fraudsters are changing their behaviors in order to take advantage of the things that are changing so quickly in your program. And again, ease of use so that you can leverage all your resources instead of having a bottleneck. That was a long-winded way of answering your question, I think.

Jeff Harrell: Jason, I love how you described it as a tool. So I imagine with millions of transactions you need a tool to make sense of all that data, any examples that you can share about tools that you guys are using?

Jason Helmandollar: Yeah, I'd love to. I'll just give you a couple examples of some of my favorites. So there are established archetypes of fraud. So really when I say a tool, we think of it more as a suite of tools that can help you with the various... And when I say archetypes, I mean things like unbundling and services not rendered and things like that. But one example I'll give you is our impossible day tool. So this is the idea that individuals are claiming to work more than what's humanly possible in a given day. So this is potentially a very difficult analysis project where you need to, first of all, you might already have a target in mind, and now you're going to go gather all of their services, you're going to assign times and minutes to all of the services that they've done and then add that all together on a 24-hour basis And then try to see if there's some sort of pattern and all of that. We have a tool that does all of that for you and does it for every provider.

Jason Helmandollar: So then you can go in and just explore providers who are working long days, and you can control for example, threshold. So I want to see providers who are claiming to work greater than 18-hour days, or 24 hour days or something like that. So that's particularly important in this time frame, because I mentioned earlier about relaxation of EVV rules and things like that, the electronic visit verification, where what we're seeing are things like therapists, home health aides, personal care assistants who are seemingly working, I've seen providers who've claimed to work over 200 hours in a single day. What's probably actually happening in a lot of those cases is you have unlicensed workers who are doing this work, assuming most of it's going on, but because they can't build being unlicensed, they bill it all as if this one person or two people had done the work.

Uncovering Improper Behavior

Jason Helmandollar: So what happens is that one person suddenly looks like they've done 200 hours in a day, which is not allowed, that's improper billing, that sort of thing. So the impossible day tool can quickly and easily help you uncover all sorts of different schemes that might be going on. Another tool I've mentioned really briefly that is one of my favorites is it's a tool that we call event storyboard. And it's the idea of, there are all sorts of behaviors that are going on out there, and the best people to uncover those behaviors are the people who are investigating them every day. And you encounter a behavior... I'll just give you an example, a behavior might be something like, I'm a medical equipment supply company and I bill for a nebulizer kit. So this is a kid's nebulizer, and it comes with the mask, and it comes with all the tubing that you need.

Jason Helmandollar: Everything that you need is all in this one kit. Well, on the same day, I also bill for three replacement masks. Now these are only supposed to be billed if they lose their mask and need a new one, but I'm just going to go ahead and tack on all these extra things. So that becomes a behavior, a nebulizer kit along with extra tubing or extra face mask replacement items on the same day. So with legacy tools, how do I go about, "This is a brand new behavior I'd never thought of before, so I just want to test that against my data and see if it's even happening." With legacy tools that is a very involved analysis project has to occur in order to go look for something new, a new behavior.

Jason Helmandollar: With our tool event storyboard it's as easy as going in and saying, "Okay, on this side I'm going to pick the service nebulizer kit, on this side I'm going to pick the replacement items," and then I'm going to say, "On the same day for the same recipient by the same provider, when does this happen?" And I hit run. And within 30 seconds, I'm looking at results across my entire Medicaid program, who are the providers that have done this? How much have they done this? Who are the recipients that have supposedly received all of these extra items? And I can just start exploring and finding cases versus having to undertake a project. And what ends up happening is when you know in your head that the only way I can explore this as a two-week project, you just let it go and you move on to the next thing that you have to do for your job.

Jason Helmandollar: Instead of saying, "You know what? I'm going to take five minutes and just see if this is happening or not." And that's what's so important about analytic tools is you can be fast, and responsive, and nimble and explore your own ideas and really just get out there and make a difference without being bogged down technologically.

Jeff Harrell: Well, here at Tyler Technologies, we love when technology can help solve problems and provide efficiency, and speed and ease of use. So thanks for those examples. Well, Jason, this has been awesome. I want to finish with this final question around pandemic and I described it as a pivot, you said it was much more than that, but do you see some of these changes we've seen from the pandemic becoming a little bit more of the new normal going forward?

Jason Helmandollar: Definitely. Two things, I guess, I'll bring up for this. Number one is telehealth. I don't see telehealth going away anytime soon. And the reason for that is it's the same reason we've all been working from home during this time, most of us, and now we're used to it. So when suddenly your company or whoever you work for starts saying, "I think we might start going back to the office." It's like, "No, I want to just continue working from home." And we hear of a lot of companies that are going to go hybrid and things like that because it's become the new norm. Well, telehealth, I believe has become the new norm to some extent. So I just can't see that going back to its former levels in terms of utilization. So of course, all of the confusion and complications that go along with that are going to remain and will need to be addressed.

Jason Helmandollar: So that's one big thing. The other thing is don't make the mistake of thinking that fraud that has emerged during the pandemic will go away with the pandemic because it's not going to. I kind of mentioned earlier the way fraudsters think, "I want to buy that boat," and that sort of thing. But honestly, it is true that if I'm someone that I make my money by committing fraud and I've taken advantage of a situation which is a worldwide pandemic in order to increase my income by X amount, as that pandemic starts to fade, I'm not suddenly going to say, "Well, I guess it's time to go back to my old income level." No, that's not how they work. They're going to figure out ways to continue to commit fraud and to maintain that level that they've established during the pandemic.

Jason Helmandollar: So right now it's all sort of hidden in this dip that we've seen in general services. Most providers are billing a lot less right now, especially if we go back a year. But are billing less so these outlier providers that are billing more that are billing for more expensive services suddenly billing for therapy every day, instead of twice a week, those sorts of things. They're hidden in that dip. And once that dip comes back, which it already is starting, then we're going to really start seeing that, "Oh wow, we're paying a lot more suddenly than we did a year and a half ago for these types of services and those types of things."

Jason Helmandollar: So the advice I would give to states is remain vigilant and just know that this will continue and that of course, technology is at least part of your answer and can help you to address this moving forward.

Jeff Harrell: Well, Jason, this has been very enlightening. If someone wanted to get in contact with you, what's the best way for them to reach?

Jason Helmandollar: Pulselight.com probably would be... Of course, anyone listening is welcome to email me at jhelmandollar@pulselight.com, but also you can go on our website and learn about the different solutions that we have and there's a way that you can reach out to us from there.

Jeff Harrell: Awesome. Well, Jason really appreciate you joining me.

Jason Helmandollar: Hey, my pleasure.

Jeff Harrell: Well, I'm grateful to Jason for joining us and shedding some light on this issue. I know for me, you understand the impact of the pandemic but there's certain situations you don't even think of, Medicaid being one of those. Hope you enjoyed that, hope you found that informative.

Jeff Harrell: But we drop a brand new episodes every other Monday at the Tyler Tech Podcast. So please subscribe. We'd love if you liked the podcast to give us a review as well. Until next time, I'm Jeff Harrell, director of content marketing for Tyler Technologies. We'll talk to you soon.