Met with Lou Saccoccio (CEO) and Erin Carlson (Snr Director, Education and Training).
Excellent discussion regarding approaches taken to collaboration and partnership against fraud in US health care.
NHCAA are a small (12 FTEs) government and industry funded group (85 members) established in 1985 that supports a range of collaborative and educational programs including certification of fraud investigators – Accredited Health Care Fraud Investigator (AHFI) and Annual Training Conference.
Bupa are involved, mostly out of UK but also Australia (Michael Douman).
Ray Collins is very active in the space.
- SIRIS is an information sharing/case management data base hosted by LexisNexis – contract regarding use to be forwarded. Sharing this information is legal provided it is performed according to strict guidelines and relates specifically to fraud investigation. It cannot be a fishing exercise. Cases must be built on own information, but having the database allows investigators to follow up with other investigators looking at a specific concern.
- A number of firms provide a recoveries service offering – Verisk, Emdeon, LexisNexis – the standard charge is 30% commission on recoveries made.
- Case discussion roundtable meetings support information sharing around specific cases.
- Discussed the 7:1 ROI enjoyed by federal programs – much of this is returned by cases focused on recovering monies from “Pharmaceutical Off-label Marketing Fraud” and “Pharmaceutical Best Pricing Fraud” which then boosts overall figures.
- Other approaches include cross-matching for recently deceased providers (phantom providers) who continue to bill. When this practice becomes endemic in a region, moratoria are established that prevent new providers being registered in that region.
- Also look at “high cost pharmacies”, perform site visits and follow up on outliers on risk scoring.
- MITRE Corporation (originally a military technology R&D organisation akin to RAND) are now collaborating with CMS in a program called CMS Alliance to Modernize Healthcare. Thier operating model involves partnership with government agencies on a sole source basis. IP can be captured by MITRE and then commercialised as required.
- All Claims Pooling is another approach using trusted third parties – Verisk, Emdeon and LexisNexis.
- Federally-granted Recovery Audit Contracts see third parties (e.g. Performant) chase potential recoveries from providers – not appreciated by providers.
- Palantir had previously engaged with NHCAA but had since withdrawn. They have a contract with Aetna, but no one else in health was mentioned. Government entities tended to work solely with MITRE.
- NHCAA saw much opportunity to extend scope from fraud to low value care – clinical special investigation units are involved in this work, typically headed by MDs and they meet at the annual conference.
- Suggested engaging with CMS Head Dr Shantanu Agrawal who I am meeting on Wednesday.
Actions
- Erin: refer me to Allanna Lovell at MITRE for a meeting
- Erin: invite to anti-fraud conference in November
- Erin: share guidelines for intelligence sharing
Linked and attached are presentations by Shantanu Agrawal and his staff on the CMS (Centers for Medicare & Medicaid Services) scoring system they are using, as well as their latest anti-fraud initiatives.
- http://www.medscape.org/viewarticle/764496_transcript
- http://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-Releases/2013-Press-Releases-Items/2013-07-26.html
- http://www.hhs.gov/asl/testify/2014/06/t20140625a.html
