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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.