1/ 28 october 2007 / sgs internal medicare-medicaid network analysis jamie lejcar andrew needs...
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![Page 1: 1/ 28 OCTOBER 2007 / SGS INTERNAL Medicare-Medicaid Network Analysis Jamie Lejcar Andrew Needs Medicare/Medicaid Data Analysis Center](https://reader036.vdocuments.mx/reader036/viewer/2022062407/56649e185503460f94b04afb/html5/thumbnails/1.jpg)
1 / 28 OCTOBER 2007 / SGS INTERNAL
Medicare-Medicaid Network AnalysisJamie Lejcar
Andrew Needs
Medicare/Medicaid Data Analysis Center
![Page 2: 1/ 28 OCTOBER 2007 / SGS INTERNAL Medicare-Medicaid Network Analysis Jamie Lejcar Andrew Needs Medicare/Medicaid Data Analysis Center](https://reader036.vdocuments.mx/reader036/viewer/2022062407/56649e185503460f94b04afb/html5/thumbnails/2.jpg)
2 / 28 OCTOBER 2008 / SGS INTERNAL Medicare-Medicaid Network Analysis
Outline
•Gap Analysis
• Integration
•Statistical Models
•Provider Profiles
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3 / 28 OCTOBER 2007 / SGS INTERNAL
Gap Analysis
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4 / 28 OCTOBER 2008 / SGS INTERNAL Medicare-Medicaid Network Analysis
•Medicare– Medicare pays a travel fee for specimen collection
in nursing homes.• P9603 – Per Mile• P9604 – Per Trip
•Medicaid– Medicaid does not pay a travel fee for specimen
collection of nursing home recipients
Utilization – Gap Analysis
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5 / 28 OCTOBER 2008 / SGS INTERNAL Medicare-Medicaid Network Analysis
Utilization – Gap Analysis
•Medicare– Does not pay:– Very Low Density Lipoprotein (VLDL) CPT – 83719– Lipoprotein CPT – 82172
•Medicaid– CPT – 82172 and 83719 are reimbursable in
certain circumstances
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6 / 28 OCTOBER 2008 / SGS INTERNAL Medicare-Medicaid Network Analysis
Utilization Gap Analysis
NY Medicaid - CPT 82172Apolipoprotein Test
$0
$500
$1,000
$1,500
$2,000
$2,500
1 2 3 4 1 2 3 4
2006 2006 2006 2006 2007 2007 2007 2007
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7 / 28 OCTOBER 2008 / SGS INTERNAL Medicare-Medicaid Network Analysis
Utilization Gap Analysis
NY Medicaid - CPT 83719Very Low Density Lipoprotein
$0
$20
$40
$60
$80
$100
$120
$140
$160
1 2 3 4 1 2 3 4
2006 2006 2006 2006 2007 2007 2007 2007
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8 / 28 OCTOBER 2008 / SGS INTERNAL Medicare-Medicaid Network Analysis
Utilization - Gap Analysis
•Look for potential unbundling
•Multiple Ferritin / Iron tests (82728, 83550 and 83540) paid on the same date of service.
•Glycated Protein (82985) and Glycosylated Hemoglobin (83036) on the same date of service.
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9 / 28 OCTOBER 2008 / SGS INTERNAL Medicare-Medicaid Network Analysis
Utilization Gap Analysis
NY Medicaid - CPT CodesFerritin / Iron Testing
$0$5,000
$10,000$15,000$20,000$25,000$30,000$35,000$40,000
1 2 3 4 1 2 3 4 1 2
2006 2006 2006 2006 2007 2007 2007 2007 2008 2008
82728 83540 83550
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10 / 28 OCTOBER 2008 / SGS INTERNAL Medicare-Medicaid Network Analysis
Utilization Gap Analysis
NY Medicaid - CPT CodesGlycated Protein / Hemoglobin Testing
$0$20,000$40,000$60,000$80,000
$100,000$120,000$140,000$160,000$180,000$200,000
1 2 3 4 1 2 3 4 1 2
2006 2006 2006 2006 2007 2007 2007 2007 2008 2008
82985 83036
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11 / 28 OCTOBER 2008 / SGS INTERNAL Medicare-Medicaid Network Analysis
Integration of Medicare and Medicaid
•New York Medicaid Lab Payments– Medicare pays 100% (no co-insurance necessary)
– Data integration identifies co-insurance payments in Medicaid
– 500,000 claims; $4.2 million in potential Medicaid savings
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12 / 28 OCTOBER 2008 / SGS INTERNAL Medicare-Medicaid Network Analysis
Our Medi-Medi Approach - FUSION Model
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13 / 28 OCTOBER 2007 / SGS INTERNAL
Integration
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14 / 28 OCTOBER 2008 / SGS INTERNAL Medicare-Medicaid Network Analysis
Integration of Medi-Medi Data
• Identify billing aberrancies that can be missed when analyzing only Medicare or Medicaid data– Challenges involved:
• Crossover Claims
– Use of data analysis tools (SAS, JMP, i2, etc.) to identify Medi-Medi aberrancies and networks
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15 / 28 OCTOBER 2008 / SGS INTERNAL Medicare-Medicaid Network Analysis
Integration Example – Impossible Days
Provider X Impossible Days
0
20
40
60
80
100
120
140
Medicare Medi-Medi Medicaid
Program
Nu
mb
er
of
Days
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16 / 28 OCTOBER 2008 / SGS INTERNAL Medicare-Medicaid Network Analysis
Specific Examples – Provider X
Integration Example – Impossible Days
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17 / 28 OCTOBER 2007 / SGS INTERNAL
Statistical Models
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18 / 28 OCTOBER 2008 / SGS INTERNAL Medicare-Medicaid Network Analysis
Spike Models
•Analyzed regularly to detect sudden upward shifts in provider billing and/or paid amounts
•Can be specific to one provider specialty or many
•Spikes identified are studied more closely to determine if they are explainable– New provider PIN, legitimate business growth, etc.
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19 / 28 OCTOBER 2008 / SGS INTERNAL Medicare-Medicaid Network Analysis
Spike Models - Example
Lab A - Medicare Earnings by Month
$-
$20,000
$40,000
$60,000
$80,000
$100,000
$120,000
$140,000
$160,000
$180,000
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20 / 28 OCTOBER 2008 / SGS INTERNAL Medicare-Medicaid Network Analysis
Spike Models - Example
•Lab A– Identified through aberrancies in spike model
– Further analysis uncovered additional “red flags”:• Referring providers with no rendering claims• Claims paid with invalid referring UPIN• Billing irregularities with travel codes (P9603, P9604)
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21 / 28 OCTOBER 2008 / SGS INTERNAL Medicare-Medicaid Network Analysis
Referring Provider Analysis
•Lab A submitted claims with 443 different referring UPINs in 2006– Analysis involved matching Lab A’s billing data with each referring
provider’s billing data• 89 of the 443 (20.1%) referring providers had no billing history for
referred beneficiaries• $954,234 (54%) of Lab A’s paid dollars stemmed from these 89
non-rendering providers
– An additional $119,265 (4.8% of total paid dollars) was paid to Lab A in 2006 on claims with invalid referring UPINs
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22 / 28 OCTOBER 2008 / SGS INTERNAL Medicare-Medicaid Network Analysis
Referring Provider Analysis
2006 Referring UPIN Types - Lab A
5%
49%
46%
Invalid
Valid, Non-Rendering
Valid, Rendering
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23 / 28 OCTOBER 2008 / SGS INTERNAL Medicare-Medicaid Network Analysis
Referring Network Analysis
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24 / 28 OCTOBER 2008 / SGS INTERNAL Medicare-Medicaid Network Analysis
Travel Procedures
• For travel reimbursement, Medicare uses procedures P9603 and P9604– Used when lab employees travel to nursing home for specimen
collection• Lab employee has to draw specimen
– P9603: Billed per mile (greater than 20 miles)
– P9604: Billed per trip (less than 20 miles)
2006 Travel Fee Schedule
Code Fee
P9603 $0.94
P9604 $12.04
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25 / 28 OCTOBER 2008 / SGS INTERNAL Medicare-Medicaid Network Analysis
Travel Procedures
Unique Locations of Service per Day – Lab A
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26 / 28 OCTOBER 2008 / SGS INTERNAL Medicare-Medicaid Network Analysis
“Bill and Run” Scheme
•Scheme:– Providers open a PIN, bill Medicare/Medicaid
heavily, then stop suddenly• Once spike model detects the spike, provider is
gone• Need more specialized model to focus on new
providers
•“Bill and Run” model:– Analyzed all PINs opened in a given timeframe– Reviewed monthly billing amounts to detect
sudden stops in billing– Added a more real-time approach to fraud
detection
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27 / 28 OCTOBER 2008 / SGS INTERNAL Medicare-Medicaid Network Analysis
Billing Pattern
"Bill and Run" Pattern
$0
$1,000
$2,000
$3,000
$4,000
$5,000
$6,000
$7,000
5/1/
2007
5/8/
2007
5/15
/200
7
5/22
/200
7
5/29
/200
7
6/5/
2007
6/12
/200
7
6/19
/200
7
6/26
/200
7
7/3/
2007
7/10
/200
7
7/17
/200
7
7/24
/200
7
7/31
/200
7
8/7/
2007
8/14
/200
7
8/21
/200
7
8/28
/200
7
9/4/
2007
9/11
/200
7
9/18
/200
7
9/25
/200
7
Date of Service
Dollars
Bille
d
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28 / 28 OCTOBER 2008 / SGS INTERNAL Medicare-Medicaid Network Analysis
Provider Profile Report
•Report summarizes provider’s use of procedure codes– Compares given provider’s usage to his/her peer
group (i.e. same specialty)
•Statistics are calculated to identify potential aberrancies with the provider’s billing patterns
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29 / 28 OCTOBER 2008 / SGS INTERNAL Medicare-Medicaid Network Analysis
Provider Profile Report
• Initial figures describe provider’s use of various procedure codes
76536 9 439 $ 768.24 9 $ 960.30 85651 206 439 $ 1,329.28 265 $ 1,329.28 90765 57 439 $ 10,056.09 129 $ 12,703.92 99243 64 439 $ 7,420.78 70 $ 10,135.30 99212 107 439 $ 6,226.43 181 $ 8,352.87 36415 257 439 $ 2,642.10 880 $ 2,643.00 99238 66 439 $ 6,184.59 96 $ 7,738.56 80053 245 439 $ 5,853.21 593 $ 5,853.21 81003 175 439 $ 590.32 188 $ 590.32 93000 188 439 $ 6,922.32 276 $ 9,259.80 J0885 75 439 $ 96,452.16 327 $ 120,624.06 85025 254 439 $ 8,697.77 798 $ 8,698.86
Allowed Services
Allowed Charges
# of Patients
Procedure Code
Total Patients
Provider Paid Amt
PIN '123456' for 1st Half 2006
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30 / 28 OCTOBER 2008 / SGS INTERNAL Medicare-Medicaid Network Analysis
Provider Profile Report
76536 2.05% 0.87% 0.0205 0.0087 1.00 1.00 3.5 0.09185651 46.92% 8.07% 0.6036 0.0532 1.29 0.57 0.396 -0.2490765 12.98% 2.21% 0.2938 0.0426 2.26 2.46 0 099243 14.58% 3.38% 0.1595 0.0306 1.09 0.98 0.168 0.31599212 24.37% 6.39% 0.4123 0.0839 1.69 1.23 -0.478 0.44436415 58.54% 34.52% 2.0050 0.5976 3.42 1.60 -0.114 2.03699238 15.03% 5.35% 0.2187 0.0589 1.46 1.07 0.054 0.23580053 55.81% 19.65% 1.3510 0.3092 2.42 1.17 0.499 0.18881003 39.86% 7.49% 0.4282 0.0857 1.07 1.00 -0.06 0.40693000 42.82% 13.63% 0.6287 0.1518 1.47 0.99 0.355 0.365J0885 17.08% 6.44% 0.7449 0.1737 4.36 3.06 0 085025 57.86% 33.26% 1.8180 0.5686 3.14 1.52 -0.01 6.096
Ratio CPeer Ratio A
Procedure Code
Peer Ratio B
Peer Ratio C
Peer % of Patients
% of Patients
Ratio A Ratio B
•Ratios are calculated to compare provider to his/her peer group
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31 / 28 OCTOBER 2008 / SGS INTERNAL Medicare-Medicaid Network Analysis
Provider Profile Report
•“Z-scores” calculated to determine a standardized difference between provider and peer group
76536 1.73 1.52 1.52 0 16.77 21.5585651 4.69 3.38 4.52 1.6 1.26 15.4690765 5.52 3.07 4.15 -0.06 0 12.6899243 6.79 1.24 2.03 0.6 -0.1 10.5799212 6.45 1.49 1.99 0.73 -0.4 10.2636415 4.06 0.87 2.27 2.39 -0.08 9.5299238 4.23 1.38 2.04 1.83 -0.18 9.380053 3.27 1.68 1.98 1.92 0.29 9.1481003 3.35 2.99 2.41 0.27 -0.21 8.8193000 3.64 1.31 1.76 2.09 0 8.8J0885 4.63 1 2.36 0.63 0 8.6285025 3.28 1.11 2.28 2.03 -0.14 8.56
SDs - Allowed
SDs - % of Patients
SDs - Ratio A
Procedure Code
SDs - Ratio B
SDs - Ratio C
SUM - Std Deviations
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32 / 28 OCTOBER 2008 / SGS INTERNAL Medicare-Medicaid Network Analysis
Questions
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33 / 28 OCTOBER 2008 / SGS INTERNAL Medicare-Medicaid Network Analysis
Contact Information
Jamie Lejcar
717-763-5923
Andrew Needs
717-975-5466
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34 / 28 OCTOBER 2007 / SGS INTERNAL
SafeGuard Services, LLC5400 Legacy DrivePlano, TX 75024