cognosante: program integrity case management presentation
TRANSCRIPT
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Program Integrity
Case Management
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Analytics to Identify
Providers or Claims for
ReviewRetrospective Claims Editing
to Identify Overpayments
Claims Auditing
Overpayment Recovery
Provider Education
Feedback to Policies and
Systems
Investigate Fraud
Referrals
Medicaid Audit Lifecycle
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How can Program Integrity staff effectively manage audit findings, recoveries, and provider communication?
Challenge
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eSante™ ARMS™ allows organizations to: • Automate investigations
• Analyze multiple data sources with cross-dimensional analytics and rich visualization tools
• Create repeatable, auditable, defensible and recoverable investigative processes
• Control access to and custody of sensitive information
• Customize dashboards for different stakeholder roles
• Publish findings that comply with legal, regulatory and industry reporting standards
• Reduce time and cost of investigations
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Supports All Program Integrity Business Processes
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Identify Vulnerabilities
• Review claims• Analyze patterns• Identify schemes• Detect Transactions• Estimate exposure• Probe weaknesses
Evaluate Workload
• Approve pursuits• Determine/apply threshold
• Determine extrapolation, sampling
Conduct Remediation
• Assign investigation cases
• Audit cases• Enforce compliance
Manage Recoveries
•Generate demand letters
•Reconcile remittance
•Update A/R
Process Appeals
•Log appeal•Resolve appeal
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Fully Modeled
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Investigation Command & Control
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Results: • Rapid identification and
processing of improper payments
• Better understanding of cause for improper payments
• Up-to-date/quality provider data
• Streamlined communications to providers and payer agencies
Reports
Workflow
Better organized
• Suspected fraud cases well documented and qualified
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Demonstration
•Dashboard of Case Activity
•Review Case
•Attach chart
•Recovery
•RAC Reports