Download THA – October 21, 2009 Data-Mining Panel Discussion

THA – October 21, 2009
Data-Mining Panel Discussion
Talking Points
-Data Mining Overview
-Industry Status Post RAC demo project
-Provider Perspective
Reasons to Proactively Mine Data at the Provider Level
RAC, ZPIC, MIC, MAC, etc.
Law Enforcement Cases Developed from Data Mining
Data Mining Tools – Commercial v. Home-Grown
Data Mining Challenges
Government Contractors performing Data Mining on Tennessee
Provider Claims Data (Medicare and/or Medicaid)
*RAC – Recovery Audit Contractor
– Connolly Consulting
*ZPIC – Zone Program Integrity Contractor
- AdvanceMed
(currently a PSC – Program Safeguard Contractor)
*Medicaid Integrity Contractor
- AdvanceMed
*Medicare Administrative Contractor
- Cahaba Government Benefit Administrators
Select Government Programs with Contractors Performing Data Mining
on Tennessee Provider Claims Data (Medicare and/or Medicaid)
*CERT – Comprehensive Error Rate Testing Program
– Program administered by AdvanceMed
– Statistical Contractor – The Lewin Group
*PERM – Payment Error Rate Measurement Program
- Tennessee part of FY 2010 Program
- Statistical Contractor – Livanta, LLC
*PEPPER – Program for Evaluating Payment Patterns Electronic
Report
- TMF Health Quality Institute
One Program Integrity
• http://www.edssafeguardservices.eds-gov.com/onePI.asp
• A 3-part claims analysis system for data mining by contractors
and government employees (Medicaid, MFCU, OIG, DOJ, etc.)
1) The Portal or Gateway designed for “collaboration”
2) Data Analysis Tools: Business Objects & Advantage Suite
3) Role-based access to Medicare & Medicaid Data including
Hospital, Physician, DME, Home Health, Ambulance,
Pharmacy etc. for combined analysis.