Medicare-Medicaid Network Analysis

1. Medicare-Medicaid Network Analysis Jamie Lejcar Andrew Needs Medicare/Medicaid Data Analysis Center

2. Outline • Gap Analysis • Integration • Statistical Models • Provider Profiles

3. Gap Analysis

4. Utilization – Gap Analysis • Medicare • Medicare pays a travel fee for specimen collection in nursing homes. • P9603 – Per Mile • P9604 – Per Trip • Medicaid • Medicaid does not pay a travel fee for specimen collection of nursing home recipients

5. Utilization – Gap Analysis • Medicare • Does not pay: • Very Low Density Lipoprotein (VLDL) CPT – 83719 • Lipoprotein CPT – 82172 • Medicaid • CPT – 82172 and 83719 are reimbursable in certain circumstances

6. Utilization Gap Analysis

7. Utilization Gap Analysis

8. Utilization - Gap Analysis • Look for potential unbundling • Multiple Ferritin / Iron tests (82728, 83550 and 83540) paid on the same date of service. • Glycated Protein (82985) and Glycosylated Hemoglobin (83036) on the same date of service.

9. Utilization Gap Analysis

10. Utilization Gap Analysis

11. Integration of Medicare and Medicaid • New York Medicaid Lab Payments • Medicare pays 100% (no co-insurance necessary) • Data integration identifies co-insurance payments in Medicaid • 500,000 claims; $4.2 million in potential Medicaid savings

12. Our Medi-Medi Approach - FUSION Model

13. Integration

14. Integration of Medi-Medi Data • Identify billing aberrancies that can be missed when analyzing only Medicare or Medicaid data • Challenges involved: • Crossover Claims • Use of data analysis tools (SAS, JMP, i2, etc.) to identify Medi-Medi aberrancies and networks

15. Integration Example – Impossible Days

16. Integration Example – Impossible Days Specific Examples – Provider X

17. Statistical Models

18. Spike Models • Analyzed regularly to detect sudden upward shifts in provider billing and/or paid amounts • Can be specific to one provider specialty or many • Spikes identified are studied more closely to determine if they are explainable • New provider PIN, legitimate business growth, etc.

19. Spike Models - Example

20. Spike Models - Example • Lab A • Identified through aberrancies in spike model • Further analysis uncovered additional “red flags”: • Referring providers with no rendering claims • Claims paid with invalid referring UPIN • Billing irregularities with travel codes (P9603, P9604)

21. Referring Provider Analysis • Lab A submitted claims with 443 different referring UPINs in 2006 • Analysis involved matching Lab A’s billing data with each referring provider’s billing data • 89 of the 443 (20.1%) referring providers had no billing history for referred beneficiaries • $954,234 (54%) of Lab A’s paid dollars stemmed from these 89 non-rendering providers • An additional $119,265 (4.8% of total paid dollars) was paid to Lab A in 2006 on claims with invalid referring UPINs

22. Referring Provider Analysis

23. Referring Network Analysis

24. Travel Procedures • For travel reimbursement, Medicare uses procedures P9603 and P9604 • Used when lab employees travel to nursing home for specimen collection • Lab employee has to draw specimen • P9603: Billed per mile (greater than 20 miles) • P9604: Billed per trip (less than 20 miles)

25. Travel Procedures Unique Locations of Service per Day – Lab A

26. “Bill and Run” Scheme • Scheme: • Providers open a PIN, bill Medicare/Medicaid heavily, then stop suddenly • Once spike model detects the spike, provider is gone • Need more specialized model to focus on new providers • “Bill and Run” model: • Analyzed all PINs opened in a given timeframe • Reviewed monthly billing amounts to detect sudden stops in billing • Added a more real-time approach to fraud detection

27. Billing Pattern

28. Provider Profile Report • Report summarizes provider’s use of procedure codes • Compares given provider’s usage to his/her peer group (i.e. same specialty) • Statistics are calculated to identify potential aberrancies with the provider’s billing patterns

29. PIN '123456' for 1st Half 2006 Provider Profile Report • Initial figures describe provider’s use of various procedure codes

30. Provider Profile Report • Ratios are calculated to compare provider to his/her peer group

31. Provider Profile Report • “Z-scores” calculated to determine a standardized difference between provider and peer group

32. Questions

33. Contact Information Jamie Lejcar 717-763-5923 jamie.lejcar@eds.com Andrew Needs 717-975-5466 andrew.needs@eds.com

34. SafeGuard Services, LLC 5400 Legacy Drive Plano, TX 75024