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Helping NYS Achieve #1 Ranking in Medicaid Fraud Detection and Recovery

Helping NYS Achieve #1 Ranking in Medicaid Fraud Detection and Recovery

About NYS Medicaid

In New York, the Office of Medicaid Inspector General (OMIG) is an independent office responsible for enhancing the integrity of the NYS Medicaid program. They aim to prevent and detect fraudulent, abusive, and wasteful practices with Medicaid and to recover improperly expended Medicaid funds, all while promoting high-quality patient care.

The NYS Office of Attorney General’s Medicaid Fraud Control Unit (OAG-MFCU) is the largest unit within the Attorney General’s Criminal Division and the centerpiece of New York’s effort to investigate, penalize, and prosecute individuals and companies responsible for improper or fraudulent Medicaid billing schemes.

MFCU is a revenue-generating agency that recovers taxpayer money through successful identification, investigation, and prosecution of frauds committed by hospitals, nursing homes, pharmacies, doctors, dentists, nurses, and other health care entities that bill the Medicaid program.


Business Case

New York State needed a partner to help create a comprehensive and secure health care information system environment. This environment had to position NYS to meet the emerging needs of the next decade. They needed to better manage their annual $50 Billion Medicaid Program to improve fiscal oversight, program integrity and control fraud and waste through improved big data management and enhanced analytics


The Solution

CMA was selected to develop and implement a replacement Medicaid Data Warehouse (MDW) solution and assume responsibility for the operational support of the current Office of Health Insurance Programs (OHIP) Data Mart.

The MDW, and the Secure Healthcare Analytics & Resource Platform (SHARP) it runs, each play a central role in New York State’s Medicaid program. NYSDOH views the MDW as a resource serving State and local government, as well as Federal government, with plans for future expansion to use by non-government healthcare professionals.

For example, In 2012, CMA implemented an enterprise solution (The NYS Clinical Research Database) to provide fast and flexible access over 25 years of claims data and provide actionable information to achieve significant program improvements and cost savings.

The MDW meets all Health Insurance Portability and Accountability (HIPAA), including 5010, and Health Information Technology for Economic and Clinical Health Act (HITECH) requirements.

OMIG uses SHARP, within CMA’s NYS Medicaid Data Warehouse, as its key information and data analytics resource for their activities. More than 275 OMIG staff and supporting consultants execute more than 1,700 queries and reports a week.

The MFCU has more than 100 users of the SHARP solution who execute more than 350 queries and reports a week.

 


The Results

And once again, the results earned after using CMA’s platform were astounding. NYS ranked #1 in the nation for fraud detection and recovery at a little over 1% of total. Additionally, over the next five years, New York State alone accounted for more than 54 percent of the national total of fraud, waste, and abuse recoveries.

MFCU

According to their 2013 Annual Report (which reported the first full year using the platform), MFCU reported the identification of over $343 million in Medicaid overpayments.

OMIG

When SHARP went into production in June 2012, OMIG’s program integrity efforts immediately increased. There was a 34 percent increase of recoveries during 2011 –2013 ($1.73 billion) as compared to 2008 – 2010 (when OMIG used the legacy data warehouse).

In their 2013 Annual Report, OMIG reported more than $2 billion in cost savings. This first full year of using SHARP also included:

  • The recovery of a record $879 million, which was more than the two previous calendar years combined.
  • A record-breaking year identifying recoveries through fee-for-service and managed care audits ($104 million and $47 million, respectively)
  • $6.7 million of recoveries through OMIG investigations, which was the highest in five years

The benefits continued in 2014, where OMIG reported $1.8 billion in cost savings, including 1,117 finalized audits identifying more than $126 million in overpayments.

OHIP reported $418 million in Medicaid recoveries in 2016. Pro-active cost-avoidance initiatives delivered cost savings of more than $1.9 billion in 2016, an increase of over $80 million from 2015.

Presently, the recovery work is still going strong, with the most recent numbers touting $2.6 billion in Medicaid cost savings and recoveries in 2017.  

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