{"id":67,"date":"2015-04-13T09:00:45","date_gmt":"2015-04-13T09:00:45","guid":{"rendered":"http:\/\/www.ef.panicola.com\/?p=67"},"modified":"2015-04-15T11:09:41","modified_gmt":"2015-04-15T11:09:41","slug":"meeting-at-national-health-care-anti-fraud-association","status":"publish","type":"post","link":"https:\/\/www.ef.panicola.com\/?p=67","title":{"rendered":"Meeting at National Health Care Anti-Fraud Association"},"content":{"rendered":"<p>Met with Lou Saccoccio (CEO) and Erin Carlson (Snr Director, Education and Training).<\/p>\n<p>Excellent discussion regarding\u00a0approaches taken to collaboration and partnership against fraud in US health care.<\/p>\n<p>NHCAA are a small (12 FTEs) government and industry funded group (85 members) established in 1985 that supports a range\u00a0of collaborative and educational programs including certification of fraud investigators &#8211; Accredited Health Care Fraud Investigator (AHFI) and Annual Training Conference.<\/p>\n<p>Bupa are involved, mostly out of UK but also Australia (Michael Douman).<\/p>\n<p>Ray Collins is very active in the space.<\/p>\n<ul>\n<li>SIRIS is an information sharing\/case management data base hosted by LexisNexis &#8211; contract\u00a0regarding use to be forwarded. Sharing this information is legal provided it is performed according to strict guidelines and relates specifically\u00a0to 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.<\/li>\n<li>A number of firms provide a recoveries service offering &#8211; Verisk, Emdeon, LexisNexis &#8211;\u00a0<strong>the\u00a0standard charge is 30% commission on recoveries made.<\/strong><\/li>\n<li>Case discussion roundtable meetings support information sharing around specific cases.<\/li>\n<li>Discussed the 7:1 ROI enjoyed by federal programs &#8211; much of this is returned by cases focused on recovering monies from &#8220;Pharmaceutical Off-label Marketing Fraud&#8221; and &#8220;Pharmaceutical Best Pricing Fraud&#8221; which then boosts overall figures.<\/li>\n<li>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\u00a0in that region.<\/li>\n<li>Also look at &#8220;high cost pharmacies&#8221;, perform site visits and follow up on outliers on risk scoring.<\/li>\n<li>MITRE Corporation (originally a military technology R&amp;D organisation akin to RAND) are now <a href=\"http:\/\/www.mitre.org\/centers\/cms-alliances-to-modernize-healthcare\/who-we-are\" target=\"_blank\">collaborating with CMS<\/a>\u00a0in 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.<\/li>\n<li>All Claims Pooling is another approach using trusted third parties &#8211; Verisk, Emdeon and LexisNexis.<\/li>\n<li>Federally-granted Recovery Audit Contracts see third parties (e.g. Performant) chase potential recoveries from providers &#8211; not appreciated by providers.<\/li>\n<li>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.<\/li>\n<li>NHCAA saw much opportunity to extend scope from fraud to low value care &#8211; clinical special investigation units are involved in this work, typically headed by MDs and they meet at the annual conference.<\/li>\n<li>Suggested engaging with CMS Head Dr\u00a0Shantanu Agrawal who I am meeting on Wednesday.<\/li>\n<\/ul>\n<p><strong>Actions<\/strong><\/p>\n<ul>\n<li>Erin: refer me to Allanna Lovell at MITRE for a meeting<\/li>\n<li>Erin: invite to anti-fraud conference in November<\/li>\n<li>Erin: share guidelines for intelligence sharing<\/li>\n<\/ul>\n<p>Linked and \u00a0attached are presentations by Shantanu Agrawal \u00a0and his staff on the CMS (Centers for Medicare &amp; Medicaid Services) scoring system they are using, as well as their latest anti-fraud initiatives.<\/p>\n<ul>\n<li><a href=\"http:\/\/www.medscape.org\/viewarticle\/764496_transcript\">http:\/\/www.medscape.org\/viewarticle\/764496_transcript<\/a><\/li>\n<li><a href=\"http:\/\/www.cms.gov\/Newsroom\/MediaReleaseDatabase\/Press-Releases\/2013-Press-Releases-Items\/2013-07-26.html\">http:\/\/www.cms.gov\/Newsroom\/MediaReleaseDatabase\/Press-Releases\/2013-Press-Releases-Items\/2013-07-26.html<\/a><\/li>\n<li><a href=\"http:\/\/www.hhs.gov\/asl\/testify\/2014\/06\/t20140625a.html\">http:\/\/www.hhs.gov\/asl\/testify\/2014\/06\/t20140625a.html<\/a><\/li>\n<li><a href=\"http:\/\/www.ef.panicola.com\/wp-content\/uploads\/2015\/04\/WP_20150413_001.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"alignnone wp-image-59 size-full\" src=\"http:\/\/www.ef.panicola.com\/wp-content\/uploads\/2015\/04\/WP_20150413_001.jpg\" alt=\"WP_20150413_001\" width=\"1280\" height=\"720\" srcset=\"https:\/\/www.ef.panicola.com\/wp-content\/uploads\/2015\/04\/WP_20150413_001.jpg 1280w, https:\/\/www.ef.panicola.com\/wp-content\/uploads\/2015\/04\/WP_20150413_001-300x169.jpg 300w, https:\/\/www.ef.panicola.com\/wp-content\/uploads\/2015\/04\/WP_20150413_001-1024x576.jpg 1024w\" sizes=\"auto, (max-width: 1280px) 100vw, 1280px\" \/><\/a><\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Met with Lou Saccoccio (CEO) and Erin Carlson (Snr Director, Education and Training). Excellent discussion regarding\u00a0approaches 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\u00a0of collaborative and educational programs including certification of fraud &hellip; <a href=\"https:\/\/www.ef.panicola.com\/?p=67\" class=\"more-link\">Continue reading <span class=\"screen-reader-text\">Meeting at National Health Care Anti-Fraud Association<\/span><\/a><\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[13,3],"tags":[],"class_list":["post-67","post","type-post","status-publish","format-standard","hentry","category-integrity","category-note-meeting"],"_links":{"self":[{"href":"https:\/\/www.ef.panicola.com\/index.php?rest_route=\/wp\/v2\/posts\/67","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.ef.panicola.com\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.ef.panicola.com\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.ef.panicola.com\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.ef.panicola.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=67"}],"version-history":[{"count":4,"href":"https:\/\/www.ef.panicola.com\/index.php?rest_route=\/wp\/v2\/posts\/67\/revisions"}],"predecessor-version":[{"id":80,"href":"https:\/\/www.ef.panicola.com\/index.php?rest_route=\/wp\/v2\/posts\/67\/revisions\/80"}],"wp:attachment":[{"href":"https:\/\/www.ef.panicola.com\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=67"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.ef.panicola.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=67"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.ef.panicola.com\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=67"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}