Maryland Automated Fraud and Abuse Tracking Abstract
In 2007, 27 states received Medicaid Transformation Grants under Section 6081 of the Deficit Reduction Act of 2005. The grants were rewarded to states that proposed innovative methods which in the end of the two years are designed to produce better health outcomes at lower cost.
The Center for Health Transformation is highlighting states that have received these Medicaid Transformation Grants, and will be following their progress for the next two years. In order for key decisionmakers and industry leaders from around the country to learn from others’ successes, it is our intention to provide this resource in order to showcase innovative practices from across the nation. In the future, this site will be interactive, allowing program directors to submit updates and comments regarding their program.
The State of Maryland is submitting this proposal in compliance with the Medicaid Transformation Grant program (specifically, subsection (z) of Section 1903 of the Social Security Act (the Act)—Medicaid Transformation Payments, and Section 6081 of the Deficit Reduction Act (DRA) of 2005 (P.L. 109-171)—Medicaid Transformation Grants).
This application seeks funding to modernize and automate the electronic systems used by the investigative units of the Maryland Medicaid Integrity Program. The proposed system will accept data from our existing Surveillance Utilization & Review Systems (SURS) for improved case review, investigation, and recovery efforts performed by program integrity personnel. The system will create all new cases, assignments to investigators and track the improvement of management of case workflow as cases are processed (i.e., reviewed, investigated, recovered, closed). The system will allow investigators the ability to store the documents, records, and images attached to the case and/or investigation in an electronic format. In addition, the system will create and store reports and/or evidence packages with all pertinent documents. The system leverages the Medicare/Medicaid OIG Provider Sanction Database and DEA Revocation Database with automatic cross-referencing capability that notifies the investigator when a prior sanction/revocation exists. Also, the system will enable our personnel traveling to field offices to have accessibility to a fully-functional web interface through the use of an Internet-capable portable computer. Finally, the system will provide managers with full reporting capabilities to allow a new level of control and insight into daily operation, and increase the ability of the State to better track the return on investment (ROI) and measure the efficiencies gained compared to current capabilities.
According to the guidelines to apply for the transformational grant program, Maryland seeks to obtain improved methodology:
- to improve rates of collections from estates of amounts owed under Medicaid;
- to reduce waste, fraud, and abuse under Medicaid (e.g., reducing improper payment rates); and
- that can be replicated for use by other States.
This grant application details the implementation plan for transitioning from the existing operational system to a new automated system utilizing new technology offered by the vendor, FRAUDExchange, LLC (Atlanta, GA). The vendor will replace many of the manual processes the investigators and managers of the Program Integrity Unit perform currently. This funding will allow Maryland to achieve increased efficiencies and recoveries which will result in the program becoming self-sustaining within the two-year period this grant will cover. The total amount budgeted for this application is $576,228 for the two-year period (see Section 4 for Budget details and breakdowns by task and year).
Also, the proposed system has the capability to provide data to external systems in the future and a collaborative environment for investigators from different jurisdictions or regions working on the same subject areas. If this system were adopted by multiple States, the FID system could be replaced and that would allow neighboring States to collaborate in identifying abusers who cross State lines. Ultimately, this system will allow Maryland to access “exclusion flag data” exported from the case management system back to the State’s credentialing system. The reporting mechanisms in the system will also provide more accurate reporting of new investigations back to CMS under the 60-day rule.
The technology utilized by FRAUDExchange, LLC is an Internet-hosted solution that provides cost-effective tools without the need for the State to invest in more-costly hardware or software. By using a hosted solution, the State will become less dependent on an outdated technology structure that utilizes computers, software and other systems that may become obsolete. The system uses paperless document management techniques for case management allowing the State to greatly reduce the storage of paper files, which provides more cost savings and efficiencies.
A minor modification to the existing SURS systems is required to allow the case data to be transferred to the Case Management Tool (CMT). The hosted solution allows the State to use a “standardized” yet configurable system that meets our needs today and is also flexible enough to scale and accommodate future requirements. The cost structure (see Section 4 for Budget details) allows the State to pay for the service without incurring new IT infrastructure costs.
Lastly, utilizing this system will favorably position Maryland in response to forthcoming Medicaid Integrity Program (MIPs) as outlined at the NASO/SURS Conference in August, 2006.
