Innovating Healthcare Program Integrity
Explore the shift from established to new approaches in healthcare program integrity, focusing on prevention, detection, and collaborative solutions. Discover key players, strategies, and systems driving fraud prevention and detection in healthcare programs to ensure transparency and accountability while engaging public and private partners effectively.
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Presentation Transcript
Established Approach New Approach 1 Pay and Chase Prevention and Detection 2 One Size Fits All Risk-Based Approach 3 Legacy Processes Innovation Inward Focused Communications 4 Transparent and Accountable Engaged Public & Private Partners 5 Government Centric Stand Alone PI Programs Coordinated & Integrated PI Programs 6 2
Medicare Administrative Contractors (Shared Systems) CMS Common Working File (Consolidated Data) Fraud Prevention System 1 2 3 4 Payment Floor CMS Command Center Zone Program Integrity Contractors Center for Program Integrity Law Enforcement 7
APS PECOS App PTAN Denied Medicare National Site Verification Contractor Pay.gov Administrative Contractors Approved FPS CMS Analytics Future models Analytics Lab | Command Center |Provider Screening Lab 10
Medicaid Medicare Federal relationship is with State State has relationship with provider Direct relationship to provider Relationship to Provider CMS relies on States to provide Medicaid claims data CMS contractors supply Medicare claims data. Data Sources CMS collects the overpayment (Federal share) from the State, the State must collect from provider. CMS collects overpayments directly from Medicare provider. Overpayment Recovery Two systems of appeal: Provider appeals to State State appeals to CMS One appeal system Appeals 13
Program Integrity 20
