medicare-medicaid network analysis
DESCRIPTION
Medicare-Medicaid Network Analysis. Jamie Lejcar Andrew Needs Medicare/Medicaid Data Analysis Center. Outline. Gap Analysis Integration Statistical Models Provider Profiles. Gap Analysis. Utilization – Gap Analysis. Medicare - PowerPoint PPT PresentationTRANSCRIPT
1 / 28 OCTOBER 2007 / SGS INTERNAL
Medicare-Medicaid Network AnalysisJamie Lejcar
Andrew Needs
Medicare/Medicaid Data Analysis Center
2 / 28 OCTOBER 2008 / SGS INTERNAL Medicare-Medicaid Network Analysis
Outline
•Gap Analysis
• Integration
•Statistical Models
•Provider Profiles
3 / 28 OCTOBER 2007 / SGS INTERNAL
Gap Analysis
4 / 28 OCTOBER 2008 / SGS INTERNAL Medicare-Medicaid Network Analysis
•Medicare– Medicare pays a travel fee for specimen collection
in nursing homes.• P9603 – Per Mile• P9604 – Per Trip
•Medicaid– Medicaid does not pay a travel fee for specimen
collection of nursing home recipients
Utilization – Gap Analysis
5 / 28 OCTOBER 2008 / SGS INTERNAL Medicare-Medicaid Network Analysis
Utilization – Gap Analysis
•Medicare– Does not pay:– Very Low Density Lipoprotein (VLDL) CPT – 83719– Lipoprotein CPT – 82172
•Medicaid– CPT – 82172 and 83719 are reimbursable in
certain circumstances
6 / 28 OCTOBER 2008 / SGS INTERNAL Medicare-Medicaid Network Analysis
Utilization Gap Analysis
NY Medicaid - CPT 82172Apolipoprotein Test
$0
$500
$1,000
$1,500
$2,000
$2,500
1 2 3 4 1 2 3 4
2006 2006 2006 2006 2007 2007 2007 2007
7 / 28 OCTOBER 2008 / SGS INTERNAL Medicare-Medicaid Network Analysis
Utilization Gap Analysis
NY Medicaid - CPT 83719Very Low Density Lipoprotein
$0
$20
$40
$60
$80
$100
$120
$140
$160
1 2 3 4 1 2 3 4
2006 2006 2006 2006 2007 2007 2007 2007
8 / 28 OCTOBER 2008 / SGS INTERNAL Medicare-Medicaid Network Analysis
Utilization - Gap Analysis
•Look for potential unbundling
•Multiple Ferritin / Iron tests (82728, 83550 and 83540) paid on the same date of service.
•Glycated Protein (82985) and Glycosylated Hemoglobin (83036) on the same date of service.
9 / 28 OCTOBER 2008 / SGS INTERNAL Medicare-Medicaid Network Analysis
Utilization Gap Analysis
NY Medicaid - CPT CodesFerritin / Iron Testing
$0$5,000
$10,000$15,000$20,000$25,000$30,000$35,000$40,000
1 2 3 4 1 2 3 4 1 2
2006 2006 2006 2006 2007 2007 2007 2007 2008 2008
82728 83540 83550
10 / 28 OCTOBER 2008 / SGS INTERNAL Medicare-Medicaid Network Analysis
Utilization Gap Analysis
NY Medicaid - CPT CodesGlycated Protein / Hemoglobin Testing
$0$20,000$40,000$60,000$80,000
$100,000$120,000$140,000$160,000$180,000$200,000
1 2 3 4 1 2 3 4 1 2
2006 2006 2006 2006 2007 2007 2007 2007 2008 2008
82985 83036
11 / 28 OCTOBER 2008 / SGS INTERNAL Medicare-Medicaid Network Analysis
Integration of Medicare and Medicaid
•New York Medicaid Lab Payments– Medicare pays 100% (no co-insurance necessary)
– Data integration identifies co-insurance payments in Medicaid
– 500,000 claims; $4.2 million in potential Medicaid savings
12 / 28 OCTOBER 2008 / SGS INTERNAL Medicare-Medicaid Network Analysis
Our Medi-Medi Approach - FUSION Model
13 / 28 OCTOBER 2007 / SGS INTERNAL
Integration
14 / 28 OCTOBER 2008 / SGS INTERNAL Medicare-Medicaid Network Analysis
Integration of Medi-Medi Data
• Identify billing aberrancies that can be missed when analyzing only Medicare or Medicaid data– Challenges involved:
• Crossover Claims
– Use of data analysis tools (SAS, JMP, i2, etc.) to identify Medi-Medi aberrancies and networks
15 / 28 OCTOBER 2008 / SGS INTERNAL Medicare-Medicaid Network Analysis
Integration Example – Impossible Days
Provider X Impossible Days
0
20
40
60
80
100
120
140
Medicare Medi-Medi Medicaid
Program
Nu
mb
er
of
Days
16 / 28 OCTOBER 2008 / SGS INTERNAL Medicare-Medicaid Network Analysis
Specific Examples – Provider X
Integration Example – Impossible Days
17 / 28 OCTOBER 2007 / SGS INTERNAL
Statistical Models
18 / 28 OCTOBER 2008 / SGS INTERNAL Medicare-Medicaid Network Analysis
Spike Models
•Analyzed regularly to detect sudden upward shifts in provider billing and/or paid amounts
•Can be specific to one provider specialty or many
•Spikes identified are studied more closely to determine if they are explainable– New provider PIN, legitimate business growth, etc.
19 / 28 OCTOBER 2008 / SGS INTERNAL Medicare-Medicaid Network Analysis
Spike Models - Example
Lab A - Medicare Earnings by Month
$-
$20,000
$40,000
$60,000
$80,000
$100,000
$120,000
$140,000
$160,000
$180,000
20 / 28 OCTOBER 2008 / SGS INTERNAL Medicare-Medicaid Network Analysis
Spike Models - Example
•Lab A– Identified through aberrancies in spike model
– Further analysis uncovered additional “red flags”:• Referring providers with no rendering claims• Claims paid with invalid referring UPIN• Billing irregularities with travel codes (P9603, P9604)
21 / 28 OCTOBER 2008 / SGS INTERNAL Medicare-Medicaid Network Analysis
Referring Provider Analysis
•Lab A submitted claims with 443 different referring UPINs in 2006– Analysis involved matching Lab A’s billing data with each referring
provider’s billing data• 89 of the 443 (20.1%) referring providers had no billing history for
referred beneficiaries• $954,234 (54%) of Lab A’s paid dollars stemmed from these 89
non-rendering providers
– An additional $119,265 (4.8% of total paid dollars) was paid to Lab A in 2006 on claims with invalid referring UPINs
22 / 28 OCTOBER 2008 / SGS INTERNAL Medicare-Medicaid Network Analysis
Referring Provider Analysis
2006 Referring UPIN Types - Lab A
5%
49%
46%
Invalid
Valid, Non-Rendering
Valid, Rendering
23 / 28 OCTOBER 2008 / SGS INTERNAL Medicare-Medicaid Network Analysis
Referring Network Analysis
24 / 28 OCTOBER 2008 / SGS INTERNAL Medicare-Medicaid Network Analysis
Travel Procedures
• For travel reimbursement, Medicare uses procedures P9603 and P9604– Used when lab employees travel to nursing home for specimen
collection• Lab employee has to draw specimen
– P9603: Billed per mile (greater than 20 miles)
– P9604: Billed per trip (less than 20 miles)
2006 Travel Fee Schedule
Code Fee
P9603 $0.94
P9604 $12.04
25 / 28 OCTOBER 2008 / SGS INTERNAL Medicare-Medicaid Network Analysis
Travel Procedures
Unique Locations of Service per Day – Lab A
26 / 28 OCTOBER 2008 / SGS INTERNAL Medicare-Medicaid Network Analysis
“Bill and Run” Scheme
•Scheme:– Providers open a PIN, bill Medicare/Medicaid
heavily, then stop suddenly• Once spike model detects the spike, provider is
gone• Need more specialized model to focus on new
providers
•“Bill and Run” model:– Analyzed all PINs opened in a given timeframe– Reviewed monthly billing amounts to detect
sudden stops in billing– Added a more real-time approach to fraud
detection
27 / 28 OCTOBER 2008 / SGS INTERNAL Medicare-Medicaid Network Analysis
Billing Pattern
"Bill and Run" Pattern
$0
$1,000
$2,000
$3,000
$4,000
$5,000
$6,000
$7,000
5/1/
2007
5/8/
2007
5/15
/200
7
5/22
/200
7
5/29
/200
7
6/5/
2007
6/12
/200
7
6/19
/200
7
6/26
/200
7
7/3/
2007
7/10
/200
7
7/17
/200
7
7/24
/200
7
7/31
/200
7
8/7/
2007
8/14
/200
7
8/21
/200
7
8/28
/200
7
9/4/
2007
9/11
/200
7
9/18
/200
7
9/25
/200
7
Date of Service
Dollars
Bille
d
28 / 28 OCTOBER 2008 / SGS INTERNAL Medicare-Medicaid Network Analysis
Provider Profile Report
•Report summarizes provider’s use of procedure codes– Compares given provider’s usage to his/her peer
group (i.e. same specialty)
•Statistics are calculated to identify potential aberrancies with the provider’s billing patterns
29 / 28 OCTOBER 2008 / SGS INTERNAL Medicare-Medicaid Network Analysis
Provider Profile Report
• Initial figures describe provider’s use of various procedure codes
76536 9 439 $ 768.24 9 $ 960.30 85651 206 439 $ 1,329.28 265 $ 1,329.28 90765 57 439 $ 10,056.09 129 $ 12,703.92 99243 64 439 $ 7,420.78 70 $ 10,135.30 99212 107 439 $ 6,226.43 181 $ 8,352.87 36415 257 439 $ 2,642.10 880 $ 2,643.00 99238 66 439 $ 6,184.59 96 $ 7,738.56 80053 245 439 $ 5,853.21 593 $ 5,853.21 81003 175 439 $ 590.32 188 $ 590.32 93000 188 439 $ 6,922.32 276 $ 9,259.80 J0885 75 439 $ 96,452.16 327 $ 120,624.06 85025 254 439 $ 8,697.77 798 $ 8,698.86
Allowed Services
Allowed Charges
# of Patients
Procedure Code
Total Patients
Provider Paid Amt
PIN '123456' for 1st Half 2006
30 / 28 OCTOBER 2008 / SGS INTERNAL Medicare-Medicaid Network Analysis
Provider Profile Report
76536 2.05% 0.87% 0.0205 0.0087 1.00 1.00 3.5 0.09185651 46.92% 8.07% 0.6036 0.0532 1.29 0.57 0.396 -0.2490765 12.98% 2.21% 0.2938 0.0426 2.26 2.46 0 099243 14.58% 3.38% 0.1595 0.0306 1.09 0.98 0.168 0.31599212 24.37% 6.39% 0.4123 0.0839 1.69 1.23 -0.478 0.44436415 58.54% 34.52% 2.0050 0.5976 3.42 1.60 -0.114 2.03699238 15.03% 5.35% 0.2187 0.0589 1.46 1.07 0.054 0.23580053 55.81% 19.65% 1.3510 0.3092 2.42 1.17 0.499 0.18881003 39.86% 7.49% 0.4282 0.0857 1.07 1.00 -0.06 0.40693000 42.82% 13.63% 0.6287 0.1518 1.47 0.99 0.355 0.365J0885 17.08% 6.44% 0.7449 0.1737 4.36 3.06 0 085025 57.86% 33.26% 1.8180 0.5686 3.14 1.52 -0.01 6.096
Ratio CPeer Ratio A
Procedure Code
Peer Ratio B
Peer Ratio C
Peer % of Patients
% of Patients
Ratio A Ratio B
•Ratios are calculated to compare provider to his/her peer group
31 / 28 OCTOBER 2008 / SGS INTERNAL Medicare-Medicaid Network Analysis
Provider Profile Report
•“Z-scores” calculated to determine a standardized difference between provider and peer group
76536 1.73 1.52 1.52 0 16.77 21.5585651 4.69 3.38 4.52 1.6 1.26 15.4690765 5.52 3.07 4.15 -0.06 0 12.6899243 6.79 1.24 2.03 0.6 -0.1 10.5799212 6.45 1.49 1.99 0.73 -0.4 10.2636415 4.06 0.87 2.27 2.39 -0.08 9.5299238 4.23 1.38 2.04 1.83 -0.18 9.380053 3.27 1.68 1.98 1.92 0.29 9.1481003 3.35 2.99 2.41 0.27 -0.21 8.8193000 3.64 1.31 1.76 2.09 0 8.8J0885 4.63 1 2.36 0.63 0 8.6285025 3.28 1.11 2.28 2.03 -0.14 8.56
SDs - Allowed
SDs - % of Patients
SDs - Ratio A
Procedure Code
SDs - Ratio B
SDs - Ratio C
SUM - Std Deviations
32 / 28 OCTOBER 2008 / SGS INTERNAL Medicare-Medicaid Network Analysis
Questions
33 / 28 OCTOBER 2008 / SGS INTERNAL Medicare-Medicaid Network Analysis
Contact Information
Jamie Lejcar
717-763-5923
Andrew Needs
717-975-5466
34 / 28 OCTOBER 2007 / SGS INTERNAL
SafeGuard Services, LLC5400 Legacy DrivePlano, TX 75024