Best Practices in Medicaid - South Carolina
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.
View South Carolina's Official Medicaid >>
Consumer-directed care demonstrations (include number of beneficiaries served now and in any expansion plans)
South Carolina was the first state to receive a 1915(c) Independence Plus waiver for the elderly and disabled. At conclusion of a pilot phase, the waiver was approved with an effective date of July 1, 2003 - June 30, 2006. This program is known as SC Choice and is now operational statewide with approximately 200 enrollees as of January 1, 2006. SC Choice provides consumers with greater options about the types of service provided, how the services are delivered and who provides them.
The CMS website, Promising Practices in Home and Community-Based Services featured SC Choice in “Streamlined Provider Agreement for Non-Traditional Medicaid Providers”: www.cms.hhs.gov/promisingpractices.
Delivering high quality, coordinated, long term care for the disabled and/or the infirm
Through several of the state’s Real Choice Grants, partnerships have been formed between the South Carolina Department of Health and Human Services and the State Unit on Aging to create a statewide web-based system with information about aging and adult disability services known as SC Access. For further information visit the website at: www.scaccesshelp.org. Information about the state’s efforts to coordinate aging and long term care services can be found in “South Carolina: Services for Older People and People with Disabilities”: www.cms.hhs.gov/promisingpractices.
Use of health information technology (electronic health records, e-prescribing, electronic billing, etc)
The South Carolina Department of Health and Human Services has developed an automated Case Management System (CMS) to use in the operation of four home and community-base waivers. CMS has intake, assessment, care planning, service authorization, documentation, and reporting components. The system has also been used in the state’s quality management system for these waivers. See Promising Practices in Home and Community-Based Services, “South Carolina’s Case Management System” and “South Carolina: Improving Responsiveness of Service Managers to Persons’ Needs”: http://www.cms.hhs.gov/promisingpractices .
The South Carolina Department of Health and Human Services has an automated monitoring system called Care Call. This system is used for monitoring and verification of the providers delivering services under four of the state’s home and community-based services waivers. The toll-free number allows providers to check-in and check-out as they deliver services in a participant’s home, while the database interfaces with claims data to minimize fraudulent billing. The database has empowered waiver service recipients and has provided significant cost savings for the state. In addition, the database serves as a quality management tool for case managers. (From Promising Practices in Home and Community-Based Services, “South Carolina Care Call: Automated Provider Monitoring System”: www.cms.hhs.gov/promisingpractices
Additionally, in partnership with the South Carolina Budget and Control Board’s Office of Research and Statistics, the agency recently implemented a web-based HIPAA compliant, secure Client Management System. The Client Management System is designed for the provision of data collection, analysis and linkage that will be used for monitoring/tracking of services rendered to Medicaid beneficiaries by private and public sector entities. The system will allow the tracking of public sector clients across multiple agencies and other Medicaid providers to ensure better coordination and management. The purpose of the Client Management System is to enhance treatment, payment and operation of services to Medicaid beneficiaries.
The South Carolina Health Exchange (SCHIEX) allows doctors and hospitals to access the claims history of more than 700,000 Medicaid recipients. The first statewide system of its kind, SCHIEX will improve diagnostic capabilities and cut down on unnecessary tests.
Expanding coverage through private sector initiatives
Diabetes and hypertension are the two leading causes of chronic kidney disease. The South Carolina Department of Health and Human Services partnered with the National Kidney Foundation of SC, a local Nephrology practice and Abbott Laboratories to pilot a chronic kidney disease education program in December 2004. The program targets Medicaid enrolled primary care physicians who serve significant numbers of adult Medicaid patients and has been piloted in 3 SC counties to date. Under the pilot, Nephrologists provide instruction on screening for the disease through lab testing as well as diagnosing, staging and treating the disease. The Nephrologists are also available for consultation and referral when indicated. The intent of the pilot is to promote awareness about the need to screen those at risk for the disease and the importance of diagnosis and treatment for those with chronic kidney disease. Treatment can delay, and sometimes stop, the progression of chronic kidney disease to end stage renal disease. The pilot has been funded through a grant from Abbott Laboratories, which was awarded directly to the National Kidney Foundation of SC.
Transparent and publicly-accessible measurements of patient outcomes and/or quality improvements
SCHDDS has created a searchable database that allows residents to see how much money individual Medicaid providers received and how many patients they treated. The goal of the site is to provide a direct connection between Medicaid funding and what it actually purchases. In an effort to reduce administrative expenses and update more efficiently, the SCHDDS will begin paying all providers through Electronic Fund Transfers instead of paper checks.
Efforts to combat fraud and abuse
South Carolina Department of Health and Human Services has focused on improving the identification of overpayments, fraud, and abuse in the Medicaid program. This effort has paid off in increases in collections from both health care providers and Medicaid recipients. For example, federal and state funds identified and recovered as a result of fraud, abuse and overpayments increased 17% in FY 2005, for a total of $17,415,271. More importantly, increased identification of unallowable or excessive Medicaid expenditures has been the result of program innovations, which in turn have led to recommendations for improved utilization controls to further stem abuses. The following “best practices” demonstrate how South Carolina has enhanced its efforts to combat fraud, abuse, and improper payments.
• Initiation of a “self-audit” process for Medicaid providers that may be making common billing errors resulting in overpayments. We furnished the claims data to the facilities for review and validation. The facilities repaid the Medicaid program and provided corrective action plans to resolve the billing errors.
• Development of an algorithm that identifies Medicaid beneficiaries who show a pattern of “doctor shopping” in order to obtain narcotic prescriptions and other controlled substances. While this does not impact Medicaid costs overall, it allows us to better ensure that Medicaid prescription drug benefits are not being abused.
• Creation of a recipient fraud and abuse unit in the state Attorney General’s Office that focuses on the investigation and prosecution of individuals who have obtained Medicaid benefits through fraudulent means. States are required to have a Medicaid Fraud Control Unit to investigate fraud by healthcare providers, but recipient Medicaid fraud has been handled by local solicitors who had many competing priorities. Having a specialized unit has allowed DHHS to more effectively pursue recipient fraud.
• Conducting focused reviews that target abusive practices by provider types, as opposed to merely reacting to individual complaints about providers. For example, data analysis showed an unusual pattern of third party insurance denials in the claims submitted by a certain provider group. Subsequent investigations showed that these providers had not pursued coordination of benefits in accordance with Medicaid policy. Another study showed a high rate of billing by a particular provider group. These providers were using unlicensed, and un-supervised, paraprofessionals to submit multiple claims for counseling services that were not provided in compliance with Medicaid policy.
By identifying and ending these types of abuse, DHHS not only recouped the inappropriate payments from the providers but also has avoided millions of dollars in unnecessary costs. In addition, program staff have improved the level of monitoring and quality oversight of providers to ensure they are following the professional practice requirements of their licensing boards.
“Never events” – South Carolina will stop paying for medical errors that occur in hospitals. Termed, “Never Events,” these preventable medical errors have already been resolved by Medicare. South Carolina is one of the 20 states working to protect against these payments.
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?
States need flexibility to design their programs around evidence-based results. This flexibility should be provided without administrative burden (waiver application).
What are your future plans?
See Medicaid Reform plan at www.dhhs.state.sc.us