Best Practices in Medicaid - Mississippi
The Center for Health Transformation is inviting leaders from all 50 states to share their transforming solutions for the Medicaid program. In order that key decision-makers and industry leaders from around the country may learn from others’ successes, it is our intention to provide this interactive resource for showcasing the most innovative practices in the country. Please note that the following contributions have not been edited by CHT staff and will remain open indefinitely to future updates.
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Consumer-directed care demonstrations (include number of beneficiaries served now and in any expansion plans)
The Healthier Mississippi Demonstration Project authorized through a Section 1115 Waiver for a 5-year period provided a benefit package to an expanded population that included individuals with income up to 135 percent of the Federal poverty level who are aged or disabled, and are either not eligible for Medicare coverage or have Medicare coverage and a specific chronic condition. The enrollment cap was 5,000 non-Medicare beneficiaries (Medicaid only) and 12,000 Medicare beneficiaries with chronic conditions. The chronic conditions were end stage renal disease patients on dialysis, cancer patients receiving chemotherapy or radiation, transplant patients receiving anti-rejection drugs, and patients with mental illness receiving antipsychotic medications. Individuals who had Medicare coverage with chronic conditions were eligible to participate in the demonstration until December 31, 2005. These individuals were eligible for the Medicare pharmacy benefit which began on January 1, 2006. This waiver has provided benefits to the most needy of a population that were not eligible for Medicaid in Mississippi.
Delivering high quality, coordinated, long term care for the disabled and/or the infirm
The Division of Medicaid approved an incentive program for nursing facilities via the Civil Money Penalty Grant Awards Program in FY 2003. This program was designed to award facilities in substantial compliance with long term care federal requirements and those facilities that failed the requirements. This incentive award program promotes facilities rendering care to the best of their abilities be awarded through this incentive program through its Enhancement Grant with awards up to $50,000 each. The Educational Grant award program assists facilities that were not in substantial compliance at immediate jeopardy levels to obtain outside resources to assist with the facility’s need to improve its care rendered to residents in the nursing facility. A facility can be awarded up to $20,000 each for this program. The Division set aside an amount each fiscal year to award as many facilities as possible. From 2003 – 2005, a total of 12 grants have been awarded totaling approximately $325,000.00. Residents in the nursing facilities receiving the grants have directly benefited from the use of the services enhanced through these programs.
Use of health information technology (electronic health records, e-prescribing, electronic billing, etc)
Handheld Wireless Medication Management Program: Personal Digital Assistant (PDA) Device (eMPOWERx) - The State of Mississippi now has a platform for delivering clinical information and decision support through a wireless personal digital assistant. Gold Standard Multimedia has developed a wireless handheld medication management program that empowers the state's high volume Medicaid prescribers with real time access to patient specific medication histories integrated around comprehensive prescription drug information. This program provides Medicaid physicians with access to a comprehensive, unbiased drug information database integrated around timely, patient-specific medication histories (including prescriptions written by other providers) - all at the point of care. Providers will have the capability to review their patient’s medication history during the evaluation of their current medical condition, including screening this information for such things as duplicate therapy, alternative therapies from the PDL, and unnecessary or redundant prescribing. This will increase prescribing and fulfillment efficiencies as well as provide expeditious communication of PDL and benefit coverage changes. The system includes a variety of innovative tools that allow providers to better manage their Medicaid patients and combat fraud and abuse in the prescription drug benefit program. The program has consistently achieved a high return on investment to the state, and has been recognized nationally as an innovative, successful approach to medication management and cost containment in Medicaid. As to health information technology, our agency use the Pharmacy Point-of-Sale (POS) system, electronic billing, card swipe to determine eligibility and automate voice response (AVRS).
Expanding coverage through private sector initiatives
Mississippi partners with Blue Cross Blue Shields to provide health coverage for eligible children. Blue Cross Blue Shields is responsible for handling the premiums payments for the children deemed eligible under Title XXI of the Social Security Act. Senate Bill 2174 established a statewide Children’s Health Insurance Program referred to as Mississippi Health Benefits. According to DOM monthly data, we’re providing health coverage for approximately 62,737 children. The goal is to assess these children for SCHIP eligibility under a health coverage package
Transparent and publicly-accessible measurements of patient outcomes and/or quality improvements
DISEASE MANAGEMENT PROGRAM – Since April 2003, Mississippi has contracted with McKesson Health Solutions to educate and coordinate care for Medicaid beneficiaries who have been diagnosed and treated for three specific chronic diseases - asthma, diabetes and high-risk hypertension, and their providers. The overall objective of the disease management program is for realizing cost savings through a reduction in inpatient hospitalizations and emergency room visits, and effective management of their chronic disease. Clinical protocols, based on nationally recognized evidence-based practices, are used to guide beneficiaries in the management of their disease, resulting in improved health outcomes. Beneficiaries receive comprehensive disease management services, including nurse care management; patient education; provider communication/feed-back; home visits, if needed; access to mail-order pharmacy service; medical equipment/supplies; and availability to a nurse triage hotline. There are several state partners who assist McKesson in the provision of services to beneficiaries enrolled in the disease management [program. Those services include, field-based nurses who serve as case managers; mail-order/home delivery of pharmaceuticals and medical supplies; outreach workers who work assist in the education of providers about the program; federally qualified health centers who provide primary care and a medical home for beneficiaries who do not have a primary care provider; and a hospital system who provides clinical leadership and protocol review for the call center, and assists in provider education and program evaluation.
Efforts to combat fraud and abuse
The Bureau of Program Integrity conducts investigations of providers and beneficiaries suspected of fraud and/or abuse, and monitors both providers and beneficiaries’ utilization of Medicaid benefits.
Technological improvements to increase the ability to detect, investigate and recover overpayments related to fraud, abuse, and erroneous billing are now being utilized by Program Integrity staff.
The use of HealthSpotlight, Envision MMIRS Decision Support System and OmniAlert has:
- Expanded fraud detection capabilities
- Identified non-traditional utilization patterns
- Decreased the time it takes to investigate a case
- Increased the time it takes to identify and recover overpayments
- Maximized the use of staff’s time and resources
- Increased the number of fraud cases referred to the Medicaid Fraud Control Unit of the Attorney General’s Office
HealthSpotlight - is a fraud and abuse detection and reporting system with a browser-based user interface tool. Program Integrity staff access this data to investigate cases, organize the data, drill-to-detail levels of information. HealthSpotlight has specific fraud filters with algorithms that identify aberrant billing behavior. Examples: Excessive recipients per workday, excessive workload per day, ambulance trips with no associated medical service, controlled drugs without an associated physician/dentist visit and excessive hours billed per day.
Modeling techniques compare specific types of provider billings to their peers. Examples: A spike detection model looks for suspicious surges in billings. Another model uses neural or learning technology to profile providers based on data driven peer groupings.
OmniAlert - is a utilization review system. The software creates peer-to-peer comparisons of provider billings to identify providers billing in patterns that are excessive and unlike their peers. Providers with aberrant billing “except” out for billing above the norms for any service. These are then examined to determine if the billings are normal or improper.
The Bureau of Program Integrity was involved for two years with CMS (Centers for Medicare and Medicaid Services) and a few other states to develop and test promising methods to measure the accuracy of Medicaid payments. The Bureau of Program Integrity in MS was recognized for its work in the development of a Payment Accuracy training manual for this process. The results from the two pilots are being used to enhance and improve the payment accuracy of the Division of Medicaid in MS.
The Bureau of Program Integrity also utilizes onsite and desk audits of providers and beneficiaries to identify fraud and abuse of the Medicaid program. Cases are identified for audit through the following methods: Referrals received from inside and outside of the Division of Medicaid; Cases identified through Omni Alert and Health Spotlight; Weekly payment spike reports; Envision MMIRS reports; Monthly new provider reports (New provider inspections); A sample of Explanation of Medical Benefits are mailed each month to beneficiaries; Problems with codes or provider groups identified through audits, etc.; Fraud Hot Line; Medical Necessity referrals; Office of Inspector General; National Association of Surveillance Officials; Health Care Fraud Task Force; and Medicaid Fraud Control Unit.
Meetings are coordinated with Medicaid program staff to review fraud/abuse and utilization issues PI has identified and issues that have been identified by other bureaus. At these meetings PI reviews issues identified through audits in each of the program areas and discuss findings from PI audits. PI requests input and advice from program area staff on areas vulnerable to fraud and abuse for future investigations.
The Bureau of Program Integrity meets with the Medicaid Fraud Control Unit of the Attorney General’s Office to review current and future investigations. During these meetings vulnerabilities to the program are discussed to identify areas of the Medicaid program for possible investigations.
When reviewing claims for fraud and abuse, the Bureau of Program Integrity conducts an examination of the claim focusing upon anything suspicious and any signs of deception. We become aware of intelligence reports involving the subject we are reviewing and conduct a contextual data analysis which involves an examination of the providers’ aggregate billing behavior; Patient’s aggregate treatment patterns; Referral patterns; coincidences and unnatural structures in surrounding billing. Patient interviews are conducted in person or by telephone to verify relationships with providers, diagnoses, and treatments provided. If anything suspicious is identified in the review an unannounced visit to the provider to check billing and medical records is set up.
A Medicaid Eligibility Quality Control Division is set up within PI to determine the accuracy of Medicaid eligibility decisions made by the Division of Medicaid to allow or deny Medicaid coverage. In the active case review process, eligibility cases are audited for the correct establishment of eligibility for persons actively receiving benefits. From these findings the State Eligibility Error Rate is developed. In a separate audit process, persons or cases whose Medicaid benefits have been terminated or denied are examined to ensure that no one is refused benefits to which they are entitled. This division assists the Division of Medicaid’s eligibility staff in the development of corrective action measures when error patterns or trends are noted in the course of the MEQC review process.
Program Integrity is in the process of setting up a Beneficiary Health Management program. This will focus on questionable beneficiary utilization and if a pattern of abuse is identified it will allow us to lock a beneficiary into a single physician and/or pharmacy.
What changes would you make to the federal Title XIX so that you could provide better services to individuals and families on Medicaid in your state? The changes DOM would like to make to the federal Title XIX so that better services could be provided to individuals would be the following: allowing flexibility for benefit packages, streamline the waiver process, streamline technology that will improve timeliness and accuracy on eligibility determinations and re-determinations, and providing continued education and on-going training to retain a quality workforce.
What are your future plans?
The agency future plan is to embark on implementing a digital imaging program to ensure more efficient record keeping, and to move to more home and community-based services.
