Philadelphia: Medicare Fraud Summit Sharing Data Panel


Uploaded by USGOVHHS on 22.06.2011

Transcript:
OKAY. SO WELCOME TO PANEL 3, USING TECHNOLOGY AND
SHARING DATA AMONG PRIVATE AND PUBLIC PARTNERS. I WANT TO INTRODUCE MYSELF
BRIEFLY, MY NAME IS TED DOODLE, I'M THE DEPUTY DIRECTOR FOR
POLICY AND OTHER AGENCIES. I WANTED TO TAKE A QUICK
OPPORTUNITY TO INTRODUCE MYSELF TO YOU AND TALK TO YOU JUST REAL
BRIEFLY ABOUT THE PUBLIC PRIVATE PARTNERSHIP THAT WE ARE TRYING
TO BUILD BECAUSE I AM AT KEY POINT OF CONTACT FOR YOU ON
THAT. I WANT TO MAKE SURE THAT WE
CREATE A DIALOGUE AND A PARTNERSHIP TODAY.
I WANT YOU TO PLEASE REACH OUT TO ME OR MY SPECIAL ASSISTANT
AND I'LL GIVE YOU THOSE CONTACTS IN A MOMENT.
WE WANT YOU TO PROVIDE SUGGESTIONS, HAPPY TO MEET WITH
YOU IN OUR SPACE IN BALTIMORE OR DC OR WHEREVER YOUR FIRM OR YOUR
INTEREST GROUPS MIGHT BE LOCATED.
I WANT YOU TO THINK DURING THIS PANEL ABOUT WHAT TYPES OF DATA
OR STRATEGIES THAT CMS HAS, THE GOVERNMENT HAS, THAT YOUR
ORGANIZATION MIGHT BE INTERESTED IN AS FOR DATA SHARING AND I
WANT YOU TO BE THINKING ABOUT THINGS THAT PERHAPS YOU HAVE
THAT WE WOULD BE INTERESTED IN. SO, THAT IS VERY MUCH AT THE
ROOT OF THE PUBLIC PRIVATE PARTNERSHIP WE ARE TRYING TO
FOSTER. JUST A LITTLE BIT OF BACKGROUND
ABOUT MYSELF. NO, NOBODY EVER TOLD ME I LOOK
LIKE CLARK KENT. BUT, I GREW UP IN A TOWN CALLED,
SMALLVILLE AND -- 2 [LAUGHTER]
ANY WAY. BUT ANY WAY, IT'S MY CONTACT
INFORMATION HERE. MY SPECIAL ASSISTANT WHO IS
KNOWN TO MANY OF YOU. DON'T BE MISS LED, SHE KATHERINE
PESTO IN THE SYSTEM. THESE ARE THE CONTACT THAT I
JUST WANT TO LEAVE UP FOR A MOMENT.
IF I THOUGHT OF IT, I WOULD HAVE PUT IT UP, ALAN CROTMAN OF THE
MITER ORGANIZATION WHO IS WORKING WITH US IN DEVELOPING
THE PUBLIC PRIVATE PARTNERSHIP. THERE IS ABOUT 5 OR 6 FOLKS FROM
THE MITER ORGANIZATION HERE. PLEASE, THAT IS ANOTHER POINT OF
CONTACT FUR. SO PLEASE REACH OUT TO THEM.
THEY ARE WORKING CLOSELY WITH US IN THAT REGARD.
JUST WANT TO BRIEFLY INTRODUCE OUR PANEL.
GOING IN A SLIGHTLY DIFFERENT ORDER THAN IS ON THE SLIDE, TO
MY RIGHT IS JIM SCHWEITZER, THE SENIOR VICE PRESIDENT AND CHIEF
OPERATING OFFICER OF THE NATIONAL INSURANCE CRIMES
BUREAU, WHICH IS A PROPERTY CASUALTY INSURANCE INDUSTRY'S
FRAUD FIGHTING ORGANIZATION AND HAS A DISTINGUISHED RECORD AS A
POLICE MAN, A FORMER DIRECTOR OF THE SOUTH CAROLINA DEPARTMENT OF
PUBLIX SAFETY AND WITH THE FBI AS WELL.
SO, WELCOME. NEXT TO JIM IS SANE CARLSON, ONE
OF OUR KEY PRIVATE PARTNERS OF THE NATIONAL HEALTHCARE AND
ANTIFRAUD ASSOCIATION AND ERIN IS THE DIRECTOR OF EDUCATION AND
TRAINING THERE. NEXT TO HER IS OUR VERY OWN
DAVID NELSON WHO IS THE DIRECTOR OF OUR SPANKING NEW AND REALLY
NEW CAR-SMELL DATA ANALYTICS AND 3 CONTROL GROUP.
HE WILL BE SPEAKING A LITTLE BIT ABOUT THAT EXCITING CONTRACT
THAT YOU HEARD ABOUT FROM THE SECRETARY AND THEN SOME OF THE
OTHER EXCITING THINGS THAT KEY GROUP IS WORKING ON.
NEXT IS OUR FRIEND, MARY LUDDEN WHO IS A CERTIFIED FRAUD
EXAMINER NBA. SHE IS CURRENTLY WORKING FOR THE
NATIONAL GOVERNMENT SERVICES WHICH IS A SUBSIDIARY OF WELL
POINT. AND SHE IS INVOLVED IN THE
CONTRACT SINCE SHE WORKS FOR THE NATIONAL GOVERNMENT SERVICES.
JEFF BREWER ON THE END OF THE TABLE IS A CLIENT PARTNER WITH
FICO, AND THAT'S THE SAME OUT IF THAT SCORES ALL OF US WHEN WE
APPLY FOR MORTGAGES AND OTHER TYPES OF SERVICES.
BUT, HE IS HERE BECAUSE FICO USES THEIR ANALYTIC TECHNOLOGY
TOW PREVENT CREDIT CARD FRAUD AND SO HE IS GOING TO SPEAK TO
US ABOUT THAT. SO, LET'S SEE IF THERE IS
ANYTHING ELSE I NEED TO COVER. I DON'T THINK SO.
AGAIN, TED DOOLITTLE AND ANNE PESTO.
WE WANT THIS TO BE INTERACTIVE. WE HAVE GOTTEN SOME REALLY GREAT
PARTNERSHIPS OUT OF FORMER FRAUD SUMMITS, INCLUDING ONE KEY
INITIATIVE THAT IS REALLY GOING TO BE A LOT OF FUN TO WORK ON
THAT WE JUST HAD A BIG PRESENTATION ON AND A MEETING
WITH A NEW PARTNER LAST WEEK. SO I'M VERY HOPEFUL IN A FEW
MONTHS THERE WILL BE A SIMILAR PROJECT COMING OUT OF THIS ROOM.
PLEASE CONNECT WITH US. DURING A BREAKOUT SESSION OR OFF
LINE. SO WITHOUT FURTHER ADIEU, I'LL
GIVE THE FLOOR TO JIM. 4 THANKS.
>> OKAY. I GUESS IT'S STILL MORNING,
ABOUT 5 MORE MINUTES. SO GOOD MORNING AND I'M VERY
PLEASED TO HAVE AN OPPORTUNITY TO TELL YOU A LITTLE BIT ABOUT
NATIONAL INSURANCE CRIME BUREAU. NATIONAL INSURANCE CRIME BUREAU
IS AS THE SLIDE REFLECTS IS PC CRIME-FIGHTING ORG.
I'D LIKE TO EMPHASIZE WHEN WE TALK ABOUT NICB IN RELATION TO
FIGHTING FRAUD AS A NONPROFIT STATUS.
IT GIVES US A UNIQUE OPPORTUNITY TO SIT AND SORT OF A SAFE HARBOR
FOR OUR MEMBERS ALLOWING US TO COLLECT AND SHARE INFORMATION
WITH MULTIPLE PARTNERS. WE ARE LOCATED OUT OF CHICAGO.
300 PLUS EMPLOYEES. 175 EMPLOYEES OF THOSE ARE
INVESTIGATORS, LOCATED THROUGHOUT THE UNITED STATES.
WE ARE FUNDED THROUGH THE PROPERTY AND CASUALTY INDUSTRY.
1100 MEMBER COMPANIES MAKE UP OUR MEMBERSHIP.
AND WE HAVE BEEN AROUND FOR 100 YEARS NEXT YEAR.
SO WE ARE VERY PROUD OF THAT AND WE ARE GETTING STRONGER AND AS
WE LOOK AT THE FRAUD FIGHT ACROSS THE COUNTRY, AND LOOK AT
WHAT OUR MEMBERS ARE CONCERNED ABOUT, WE ARE GRAVITATED FROM
OUR HISTORICAL PLACE IN THE FRAUD FIGHT WITH AUTOMOBILE
FRAUD, VEHICLE FRAUD, AND VEHICLE THEFT TO PLACING A HANDY
EMPHASIS AND PRIVATEY ON MEDICAL FRAUD.
BEFORE I SHOW YOU THE BUSINESS MODEL, LET ME GO AHEAD AND DO
THAT. I THINK THAT GIVES YOU -- THIS
VERY SIMPLY SETS OUT HOW WE ARE POSITIONED TO BECOME A SIGN POST
FOR OUR MEMBERSHIP. 5 AND IF YOU LOOK AT THE TOP
THERE, YOU HAVE VARIOUS INSURANCE COMPANIES.
AND EACH OF THOSE INSURANCE COMPANIES ARE CERTAINLY IN
BUSINESS TO MAKE A PROFIT. AND THEY FIGHT WITH EACH OTHER
VERY AGGRESSIVELY EVERY SINGLE DAY.
YOU DON'T HAVE TO LOOK ANY FURTHER THAN THE GEIKO GECKO OR
THE MAYHEM GUY FROM ALLSTATE ORF FLOE AT PROGRESSIVE TO KNOW THEY
ARE FIGHTING EVERY DAY FOR MARKET SHARE.
BUT THE BEAUTY OF THIS MODEL IS THAT THEY ALL COME TOGETHER
UNDER THE UMBRELLA OF THE NATIONAL INSURANCE CRIME BUREAU
TO FIGHT AGAINST FRAUD. THEY SHARE INFORMATION WITH US
THAT THEY DON'T SHARE WITH EACH OTHER.
SO WE STAND AT THAT APEX WHERE WE ARE ABLE TO COLLECT CLAIMS
INFORMATION, ANALYZE CLAIMS INFORMATION THAT COMES FROM
THESE 1100 MEMBERS AND LOOK AT IT STRICTLY FROM THE PERSPECTIVE
OF FRAUD. THAT IS OUR ONLY BUSINESS AND
OUR CONSTITUENCIES IN THAT FIGHT ARE OUR MEMBERS AND LAW
ENFORCEMENT. AS YOU CAN SEE, WE WORK IN
VARIOUS AREAS OF FRAUD TO INCLUDE LIABILITY OR MEDICAL
FRAUD, PROPERTY FRAUD, WORKERS' COMPENSATION FRAUD, VEHICLE
FRAUD AND THE LIKE. ONCE WE GET THAT INFORMATION,
THEN WE USE THE TOOLS THAT WE HAVE AT NICB TO LOOK AT THE
INFORMATION AND TRY TO TURN IT INTO SOME ACTUAL INTELLIGENCE.
THE CHART REPRESENTS THAT ACTABLE INTELLIGENCE.
THAT INFORMATION IS THEN PROVIDED TO OUR LAW ENFORCEMENT
PARTNERS ALONG WITH OUR 6 INVESTIGATIVE EFFORTS TO VERY
SIMPLY PUT, MAKE CRIMINAL CASES AGAINST FRAUDSTERS.
THAT'S A SIMPLE VERSION. THE TOOLS THAT WE UTILIZED I
THINK ARE VERY REPRESENTATIVE OF THE GOAL IN WHICH ALL OF US
SHARE HERE TODAY AND THAT IS THE ABILITY TO TAKE INFORMATION OR
DATA. BECAUSE AS WE ALL KNOW IN OUR
WORLD TODAY, IT'S ALL ABOUT THE DATA.
TAKING THAT DATA AND TURNING IT INTO SOME ACTIONABLE
INTELLIGENCE AND INTELLIGENCE THAT COULD BE AT SOME TYPE OF
ACTIVITY TAKEN ON THAT. THE WAY THE NICB DOES THAT IS IN
SEVERAL WAYS. WE PRODUCE ALERTS.
WE NOTIFY OUR MEMBERS OF FRAUD TRENDS THAT WE, BY LOOKING AT
THEIR DATA COLLECTIVELY, WE CAN PUSH BACK OUT TO THEM AND GIVE
THEM SOME INDICATIONS OF FRAUDULENT SCHEMES THAT THEY MAY
ENCOUNTER OR HAVE ENCOUNTERED AND WHERE THEY ENCOUNTER IT,
FORWARD US THAT INFORMATION SO WE CAN ADD IT TO THE DATA THAT
WE ALREADY HAVE IN HOPES OF CREATING THESE INVESTIGATIONS
AND CASES. THEY ALSO SENT TO US THE
QUESTIONABLE CLAIMS. THESE ARE CLAIMS THAT THROUGH
NICB TRAINING THE CLAIMS HANDLERS AND EACH OF THESE
ORGANIZATIONS BECOME MORE ASTUTE TO LOOKING FOR THE RED FLAGS, IF
YOU WANT TO CALL THEM THAT. THEY ARE FRAUD AND AS YOU LOOK
AT A CLAIM AND LOOK AT HOW IT HAS BEEN PROCESSED OR WHAT THE
INFORMATION IS IN THAT CLAIM, ASK THE PROPER QUESTIONS OF THE
PERSON MAKING THE CLAIM AND TAKE THAT INFORMATION AND THEN REVIEW
IT. 7 WHEN THAT SCENE AS A
QUESTIONABLE CLAIM, WE'LL SEND THAT TO THE STATE FRAUD BUREAUS
AND AT THE SAME TIME IT'S AUTOMATICALLY SENT IN 47 STATES
TO THE NATIONAL INSURANCE CRIME BUREAU.
WE TAKE THOSE QUESTIONABLE CLAIMS AND TRIAGE THOSE.
WE SCORE THEM. AND THEN WE PUSH THEM BACK OUT
TO OUR INVESTIGATORS IN THE FIELD TO WORK CASES BASED ON
THOSE QUESTIONABLE CLAIMS. AGAIN, ALL WE ARE SAYING AT THAT
POINT AND ALL WE SAY AT THE NATIONAL INSURANCE CRIME BUREAU,
THOSE ARE INDICATORS OF FRAUD. WE ARE NOT IN A POSITION TO CALL
ANYBODY A FRAUDSTER OR TAKE ANY ACTION AGAINST THE FRAUDSTER ON
OUR OWN. BUT WHAT WE ARE ABLE TO DO IS
LEVERAGE THAT INFORMATION TO SUPPORT LAW ENFORCEMENT.
SOMETHING WE ARE VERY EXITED ABOUT, THAT'S VERY RECENT, IS
SOMETHING WE ARE CALLING AN ALERT.
HISTORICALLY, OUR DATA HAS BEEN ON THE CLAIMS SIDE.
THE METAWARE ALERTS ARE NOW THE RESULT OF INFORMATION THAT IS
COMING OFF THE BILLING SIDE LIKE YOU HEARD TALKED ABOUT HERE THIS
MORNING AS IT RELATES TO WHAT CMS IS EXITED ABOUT DOING WITH
MEDICARE AND MEDICAID DATA. WE ARE DOING WITH THE PROPERTY
AND CASUALTY DATA. THAT IS, LOOKING AT THE BILLING
INFORMATION, ANALYZING THAT BILLING INFORMATION, TREE ASHING
THAT INFORMATION, AND LOOKING FOR BILLING PATTERNS, THE TYPE
OF THINGS YOU HEARD ABOUT THIS MORNING FROM SOME OF THE OTHER
PRESENTERS, THAT ARE PRESENT IN THAT DATA BUT HISTORICALLY
SHOULD NOT BEEN PULLED OUT. 8 SO USING THOSE ALERTS AND
METAWARE ALERTS, WE ARE ABLE TO NOTIFY OUR MEMBERSHIP OF THE
POTENTIAL FRAUD INDICATORS OF FRAUD AND GIVE THEM SOME
INFORMATION THAT MAY BE HELP THEM AS THEY ADJUDICATE CLAIMS
IN THEIR SYSTEM. WE HAVE, IN PLACES AS WELL
SEVERAL MAJOR MEDICAL TASK FORCES AROUND THE COUNTRY.
THEY ARE MADE UP OF AGENTS FROM THE NICB WORKING CLOSELY WITH
ANALYSTS FROM NICB AND OUR LAW ENFORCEMENT PARTNERS WITH THE
HEAT TASK FORCES AT HHS AND DOJ PLACED AROUND THE COUNTRY.
AGAIN, LEVERAGING THE PROPERTY AND CASUALTY INFORMATION AGAINST
INFORMATION THAT WE ARE NOT AWARE OF BUT THAT THOSE THAT ARE
PLAYING ON THE PUBLIC SIDE OR ON THE PRIVATE HEALTH SIDE MAY BE
AWARE OF. AND THEN BUILDING STRONGER
CASES. AT THE END OF THE DAY, THOSE
PROVIDERS AS HAS BEEN SAID ALL MORNING LONG, 99% OF WHICH ARE
HONEST, TRYING TO CARRY OUT THE RESPONSIBILITIES THEY HAVE TO
THE PUBLIC TO PROVIDE MEDICAL TREATMENT, THEY ARE FINE.
BUT IT IS A SMALL PERCENTAGE OF FRAUDSTERS ON THE PROVIDER SIDE
THAT ARE GOING AFTER ALL THREE ASPECTS OF THE HEALTH SYSTEM.
THE PROPERTY AND CASUALTY SIDE OF COURSE, MEDICAID AND MEDICARE
SIDE AND THE PRIVATE PAYORS. AND AS WE STRENGTHEN AND DRAW
MORE ATTENTION TO THOSE FRAUDSTERS ON THE PNC SIDE OR
THE PUBLIC SIDE OR HEALTH SIDE, WE PUSH THEM INTO OTHER AREAS.
SO IT'S REALLY CRITICAL AS WE SIT HERE TODAY TO LOOK AT WHAT
IS WE CAN LEVERAGE THE INFORMATION THAT WE HAVE WITH
THE INFORMATION THAT THE PUBLIC 9 SIDE HAS AS WELL AS THE PRIVATE
HEALTH COMPANIES HAVE IN AN EFFORT TO STRENGTHEN THE ENTIRE
SYSTEM VERSUS TAKING FRAUDSTERS FROM ONE SIDE AND LETTING THEM
KNOW THAT HEY, IT'S NOT SAFE HERE BUT IF I GO OVER THERE, I'M
GOING HAVE A GREATER IMPACT AND OBVIOUSLY BE ABLE TO COLLECT
MORE MONEY WITHOUT FEAR OF REPRISAL.
THAT'S A VERY, VERY SHORT SUMMATION OF WHAT WE DO AND HOW
WE DO IT. RELATIVE TO THE MEDICAL CLAIM.
>> THANK YOU. ERIN CARLSON WITH THE NATIONAL
HEALTHCARE ANTIFRAUD ASSOCIATION.
>> THANK YOU. AND THANK YOU FOR THIS
OPPORTUNITY TO PROVIDE SOME INFORMATION ABOUT THE
ASSOCIATION. ABOUT US, WE ARE FOUNDED IN 1985
BY SEVERAL PRIVATE INSURERS TOGETHER WITH FEDERAL AND STATE
GOVERNMENT OFFICIALS AND WE HAVE THE LEADING NATIONAL
ORGANIZATION FOCUSED EXCLUSIVELY ON THE HEALTHCARE FRAUD.
WE ARE A PRIVATE PUBLIC PARTNERSHIP.
OUR MEMBERS COMPRISED MORE THAN 100 PRIVATE HEALTH INSURERS
LISTED THERE AS WELL AS UNIQUELY WE ALSO REPRESENT PUBLIC
ORGANIZATIONS. THERE IS PUBLIC SECTOR LAW
ENFORCEMENT AND REGULATORY AGENCIES HAVING JURISDICTION
OVER HEALTHCARE FRAUD COMMITTED AGAINST THE PRIVATE PAYORS AND
PUBLIC PROGRAMS. OUR MISSION STATEMENT IS TO
PROTECT AND SERVE THE PUBLIC INTEREST BY INCREASING AWARENESS
AND IMPROVING DETECTION, INVESTIGATION, CIVIL AND
CRIMINAL PROSECUTION AND 10 PREVENTION OF HEALTHCARE FRAUD.
WE PURSUE THAT MISSION SEVERAL WAYS.
I'M GOING TO FOCUS ON THE FINAL POINT IN TODAY'S DISCUSSION BUT
WE MAINTAIN A VERY STRONG PUBLIC-PRIVATE RELATIONSHIP IN
COMBATING HEALTHCARE FRAUD AS I CAN SAY THIS AS MANY EVER YOU
ARE FACULTY AT OUR CONFERENCES. WE OFFER UNPARALLELED EDUCATION
AND TRAINING THROUGH OUR INSTITUTES FOR HEALTHCARE FRAUD
PREVENTION. WE SERVE AS A NATIONAL RESOURCE
FOR HEALTHCARE AND FRAUD INFORMATION AND PROFESSIONAL
ASSISTANCE TO GOVERNMENT INDUSTRY AND THE MEDIA.
AND AS I'M GOING TO FOCUS TODAY'S TALKS, WE PROVIDE
OPPORTUNITIES FOR PRIVATE AND THE PUBLIC SECTOR INFORMATION
SHARING. WE DO THIS FOUR WAYS.
THE FIRST ONE I'D LIKE TO FOCUS ON IS OUR DATABASE.
WE CREATE OPPORTUNITIES FOR A NUMBER OF ORGANIZATIONS AND LAW
ENFORCEMENT TO SHARE HEALTHCARE -- I'M GOING TO BACK
UP AND SHARE ABOUT OUR INFORMATION SHARING ARRANGEMENTS
AND AGREEMENTS BECAUSE WE ARE AGAIN, HEALTH INSURANCE COMING
TOGETHER TO SHARE INFORMATION ON CASES AND AS YOU MENTIONED, A
COMPETITIVE BUNCH BUT WE FOUND WAYS TO WORK THIS AND WAY THAT
IS WE COULD SHARE INFORMATION WITH LAW ENFORCEMENT AND LAW
ENFORCEMENT CAN SHARE WHAT INFORMATION THEY CAN WITH US IN
THESE BOUNDARIES. AND WE DO THAT THROUGH OUR
INFORMATION SHARING AGREEMENT. AND THIS AGREEMENT PROHIBITS
MEMBERS FROM TAKING AN ADVERSE ACTION AGAINST THE PROVIDER
WITHOUT THE MEMBER HAVING 11 INDEPENDENTLY DEVELOPED THEIR
OWN EVIDENCE OF FRAUD AGAINST THE PROVIDER.
OUR MEMBERS ALSO AGREE THAT INFORMATION RECEIVED FROM US
RELATING TO THE INVESTIGATION OF PROVIDERS RESPECTED -- EXPECTED
OF COMMITTING HEALTHCARE FRAUD MUST BE CONTAINED TO THE
ANTIFRAUD UNIT OF THE ORGANIZATION.
THEY CAN'T USE THAT INFORMATION OUTSIDE OF THE ORGANIZATION.
OUR DATABASE EMPOWERED BY LEXUS NEXUS, ALLOWS OUR MEMBERS TO
EFFECTIVELY SHARE INFORMATION BY THE POTENTIAL FRAUDULENT
ACTIVITY THROUGH A WEB-BASED PLATFORM.
MEMBERS BOTH INPUT CASE INFORMATION ON CURRENT
INVESTIGATIONS AS WELL AS USE DATABASE TO SEARCH FOR EMERGING
SCHEMES OR SEARCH DIRECTLY ON PROVIDERS.
DESIGNED TO ASSIST MEMBERS IN IDENTIFYING OTHER PROVIDERS WHO
INVESTIGATIVE INTERESTS -- OTHER MEMBERS WHO HAVE INVESTIGATIVE
INTERESTS IN THE SAME PROVIDER. THE IDENTIFICATION FOSTERS A
MORE EFFICIENT UTILIZATION OF INVESTIGATIVE RESOURCES BY
POOLING INFORMATION AND ENHANCING PROSECUTION APPEAL
THROUGH THE IDENTIFICATION OF MULTIPLE VICTIMS.
WE ALSO HOST THE TRADITIONAL INFORMATION SHARING MEETINGS.
WE DO THESE 3 TIMES A YEAR WHERE COMMERCIALS INSURERS AND THE
GOVERNMENT ENTITIES MEETS DIRECTLY WITH OUR PEERS TO SHARE
SPECIFIC CASE INFORMATION ABOUT CURRENT INVESTIGATIONS AND
EMERGING SCHEMES. INFORMATION IS SHARED ON ACCESS
CASES AND EDUCATIONAL PRESENTATIONS ABOUT DETAILS OF
SPECIFIC SCHEMES INCLUDING 12 APPROPRIATE USE OF CODING,
MEDICAL DOCUMENTATION, STANDARDS IN NECESSITY ARE ALSO PRESENTED.
RECENT TOPICS INCLUDE HOME HEALTH, MEDICAL IDENTITY THEFT,
DRUG TESTING, LABORATORY SCHEMES, CRIMINAL ACTIVITY AND
HEALTHCARE. WE ALSO HAVE A VEHICLE WHERE THE
FEDERAL AGENCIES CAN REACH OUT TO THE PRIVATE SIDE THROUGH WHAT
WE CALL OUR REQUEST FOR ASSISTANCE.
AND IT'S A UNIQUE TOOL IN THE WAR AGAINST HEALTHCARE FRAUD
ALLOWS PROSECUTORS AND LAW ENFORCEMENT AGENCIES TO PARTNER
TO SUBMIT INQUIRIES CONCERNING SPECIFIC CASES OF SUSPECTED
HEALTHCARE FRAUD AND DISTRIBUTION TO THE NACA PRIVATE
NUMBERS. THE RA PROCESS IS QUICK AND
EFFICIENT AND ASSISTING CASE DEVELOPMENT AND THE IDENTIFYING
OF ADDITIONAL VICTIMS OF FRAUD TO LAW ENFORCEMENT AGENTS
PROVIDING SPECIFIC PROVIDER INFORMATION OFTEN SSN AND
REQUEST THE PRIVATE HEALTH PLANS REACH OUT IF THEY HAVE OPEN
INVESTIGATION OR HAVE POTENTIAL EXPOSURE RELATED TO PROVIDER IN
QUESTION. NHCA HELPS TO RESPOND DIRECTLY
TO THE LAW ENFORCEMENT AGENCY. OFTEN HELPING LAW ENFORCEMENT
IDENTIFY ADDITIONAL VICTIMS, TYPICALLY IN THE MILLIONS OF
DOLLARS AND ADDITIONAL CHARGES. I THINK IT'S EVIDENCE EARLIER IN
THE INVESTIGATION THAT YOU HAD SEEN IN THE PREVIOUS PANEL, HOW
THIS WORKS TO BUILD THIS TYPES OF CASES.
AND THEN FINALLY, MY LAST POINT, OUR AD HOC WORKERS.
ON AN AS NEEDED BASIS, ANY STATE WILL COORDINATE THE DEVELOPMENT
OF A TASK FORCE TO GATHER 13 RESOURCES AND DATA NECESSARY TO
COMBAT EMERGING PERVASIVE SCHEMES.
THERE ARE TWO EXAMPLES I WANT TO SHARE TODAY.
ONE IS A TASK FORCE CREATED IN 2009.
WE CALL IT SOUTH FLORIDA WORK GROUP.
ADDRESSES THE HIV HOME INFUSION SCHEME THAT PLAGUED MEDICARE AND
THEN TO SOME OF THE PRIVATE PLANS AS WELL.
AND ALSO A FACTOR 8 WORKERS THAT HELPS IDENTIFY PHANTOM
PHARMACIES. THIS HAS PHANTOM EMPLOYERS AND
EMPLOYEES AND WE WATCHED THIS SCHEME AS IT MOVED FROM SOUTH
FLORIDA AND THEN THROUGH THIS WORK GROUP REALIZED IT HAD MOVED
TO WISCONSIN AND THEN TO NEW JERSEY.
IN BOTH INSTANCES, NHCA COORDINATED DATA FROM THE PLANS
AND DATA MINING ACTIVITIES AND DISCUSS SCHEME MOVEMENT AND
PROVIDER FORMS FOR NETWORKING TO BUILD RELATIONSHIPS BETWEEN THE
PLAN INVESTIGATORS AND LAW ENFORCEMENT IN THESE CASES.
THIS IS OUR CONTACT INFORMATION. AND WE'LL TAKE QUESTIONS AT THE
END. THANK YOU.
>> LET PEOPLE HAVE A MOMENT TO GET THAT CONTACT DOWN.
AS I INTRODUCE DAVE NELSON WITH THE CENTER FOR PROGRAM
INTEGRITY. THANK YOU, DAVID.
>> I'M TRULY EXITED TO BE HERE THIS MORNING OR THIS AFTERNOON
AS IT IS NOW. TO TALK ABOUT THE
TRANSFORMATIONAL WORK THAT WE ARE DOING AT CMS.
AS I SHARED WITH MORE THAN 300 PRIVATE SECTOR ORGANIZATIONS AT
THE CENTER FOR PROGRAM INTEGRITY 14 INDUSTRY DAY, 9 MONTHS AGO, I
HAVE THE BEST JOB IN THE WORLD. 25 YEARS OF EXCITING ROLES OF
PRIVATE SECTOR, HIGH-TECH INDUSTRY-TYPE OF JOBS AND I
FINALLY HAVE A JOB EVEN MY 11-YEAR-OLD CAN UNDERSTAND NOW.
I FIGHT THE BAD GUYS WITH DATA AND SOPHISTICATED COMPUTERS.
IT'S A SIMPLE CONCEPT AND NOW WE AT CMS ARE LEVERAGING THE
KNOWLEDGE AND EXPERIENCE OF THE PRIVATE SECTOR TO IMPLEMENT
PROVEN ANALYTIC TECHNOLOGY INTO THE POWERFUL CLAIMS PROCESSING
SYSTEMS AT CMS. THIS IS OUR VISION, MODEL THAT
WE HAVE BEEN USING FOR THE LAST NINE MONTHS OR CLOSE TO A YEAR
NOW TO TALK ABOUT WHAT IT IS WE WANT TO DO IN TWO WEEKS.
THIS IS WHAT WE ARE GOING TO BE DOING.
IT'S AN END-TO-END SOLUTION THAT MONITORS AND STREAMING CLAIMS IN
PARALLEL WITH OUR CLAIMS PROCESSING SYSTEMS.
IT'S GOT VERY RICH DATA SOURCES THAT WE BUILD OUR MODELS FROM
INCLUDING CLAIMS AND ENROLLMENT RECORDS AND INVESTIGATION AND
COMPLAINTS THAT WE RECEIVE FROM PLACES LIKE 1-800 MEDICARE OR
OIG TIPS HOTLINE. STOLEN IDs WE ARE TRACKING AT
THIS POINT FOR BOTH PROVIDERS AND BENEFICIARIES.
WE ALSO BUILD PREDICTIVE MODELS USING THIS DATA ANALYTICS AND
USING THIS RICH DATA SOURCE. AND THEN WE ARE GOING TO RUN
CONCURRENT MODELS IN THIS RISK SOLUTION THAT WILL LOOK AT THESE
STREAMING CLAIMS AND BUILD A RISK SCORE BASED ON THE
BEHAVIORS IT SEES. AND THEN FINALLY, WHAT WE'LL BE
ABLE TO DO IS PRESENT THAT, ALL OF THESE SUMMARY RECORDS IN A
WAY THAT OUR INVESTIGATORS CAN 15 WORK WITH THEM.
THEY WILL ALL BE PRIORITIZED IN WITH SO THEY CAN WORK WITH THE
RIGHT RISKIEST BEHAVIORS FIRST. BUILT ON A DATA REDUCTION
PLATFORM, WHICH NORMALIZES AND FILTERS AND TRUNCATE MILLIONS OF
LINES OF STREAMING CLAIMS, 4 MILLION CLAIMS A DAY AND ENRICH
THAT IS DATA WITH OTHER SOURCES. IT USES RULES AND PATTERN
RECOGNITION TO ISOLATE INTERESTING BEHAVIOR AND THEN AS
IT MOVES DOWN THE CHAIN, IT ACTUALLY CORRELATES THE ALERTS
AND THE RELATIVE INFORMATION THAT IT PICKS UP ON AND PRESENTS
THIS RICH ACTIONABLE INFORMATION IN A PRIOR PACKAGE THAT THE
INVESTIGATORS CAN WORK WITH. SO WE START WITH A VERY, VERY
LARGE AMOUNT OF DATA THAT IS COMING IN AND WE WHITTLE IT DOWN
ALL THE WAY TO THE POINT WHERE WE CAN ACTUALLY WORK WITH IT.
SOME OF THE IMPORTANT THINGS TO NOTE ABOUT THIS NEW TECHNOLOGY
WE ARE ROLLING OUT, IT'S NOT TOTALLY NEW.
IT'S SIMILAR TO THE TYPE OF TECHNOLOGY THAT IS USED IN
INDUSTRY TODAY. AND WE ARE LOOKING AT THE SAME
TYPES OF PROBLEMS THAT WE ARE ALSO INDUSTRY BOTH PRIVATE AND
PUBLIC ENVIRONMENTS ARE SIGHING. IT'S THE SAME TECHNOLOGY THAT IS
USED FOR A WIDE RANGE OF DIVERSE COMMERCIAL ACTIVITIES
SUCH AS RETAIL CREDIT CARD TRANSACTIONS AND SECURITY AND
THREAT DETECTION AND EVEN TELCOM NETWORK MANAGEMENT TO MAKE SURE
THAT THE TRAFFIC RUNNING CORRECTLY.
>> TIME FOR A COUPLE-POINTS. >> ANALYTIC MODELS WILL RUN IN
PARALLEL AND MONITOR CMS CLAIMS AND PAYMENT INFORMATION.
WE'LL USE A VARIETY OF DIFFERENT 16 TYPES OF RULES BOTH TRUISTIC AND
MULTIVARIATE. DIFFERENT PATTERN-TYPE
RECOGNITION AND TECHNIQUES. AND WE'LL AUTOMATICALLY
CORRELATE ALL THAT INFORMATION INTO CASES THAT OUR
INVESTIGATORS CAN WORK ON. AND THEN FINALLY, THE FRAUD
PREVENTION -- DETECTION PROCESS WILL NOT INTERFERE WITH THE
LEGITIMATE SERVICES TO MEDICARE BENEFICIARIES.
THIS IS KEY TO WHAT WE ARE DOING.
VERY IMPORTANT. AND WE DON'T WANT TO INTERFERE
WITH THE SERVICES THAT ARE BEING PROVIDED BY ALL OF THE GOOD
PROVIDERS OUT THERE. INVESTIGATORS WILL QUICKLY
CONFIRM AND TAKE ADMINISTRATIVE ACTION AND WILL BE ABLE TO, IN
SOME CASES, PREVENT PAYMENT OR PREVENT A POTENTIALLY FRAUDULENT
CLAIM. THROUGHOUT THIS TRANSFORMATION,
WE'LL COLLABORATE WITH ALL OF OUR STAKEHOLDERS, PROVIDES,
CONTRACTORS, PARTNERS, WE'LL WORK TOGETHER WITH THEM TO MAKE
SURE THAT THE MODELS WE ARE BUILDING ARE REFINED AND WORKING
THE BEST THEY CAN. >> THANK YOU VERY MUCH, DAVE.
WE'LL TURN NOW TO MARY LUDDEN FROM THE NATIONAL GOVERNMENT
SERVICES. MARY AND JEFF IF YOU TRY TO KEEP
IT TO ABOUT 7 MINUTES EACH, WE WILL HAVE A FEW MINUTES AT THE
END FIFE QUESTIONS. I CAN DO THAT.
NOT A PROBLEM. >> THANK YOU.
>> I'M PROBABLY ONE OF THE BIGGEST MEDICARE GEEKS IN THE
WORLD. I STARTED OUT IN THE DAYS WHEN
WE USED TO AUDIT HOME HEALTH 17 AGENCY PROVIDERS IN GARAGES
WHERE THEY WERE PROVIDING SERVICES TO BENEFICIARIES.
AND BACK THEN, WE USED TO RUN A LOT OF DATA ANALYTICS AND
QUERIES AND WE USED TRY AND DETECT PATTERNS AND IT WOULD BE
A YEAR-OLD PATTERN AND I KNOW SOME OF THOSE APPROACHES WE USE
BECAUSE THEY ARE VALUABLE IN DETECTING TRENDS BUT I THINK I'M
ONE OF THE LUCKIEST PEOPLE BECAUSE RIGHT NOW I HAVE ONE
FOOT IN MY TRADITIONAL WORLD OF PAY AND CHASE WHICH IS WHERE I'M
COMFORTABLE SOMETIMES BUT THE MOST EXCITING PART OF MY JOB IS
LAUNCHING THE UPFRONT EDITING AND DATA ANALYSIS THAT WE ARE
CURRENTLY PROCURING THE CENTER FOR PROGRAM.
SO, HIT THE SLIDES JUST A LITTLE BIT.
WHAT I DID DURING THIS MORNING'S SESSIONS, I WROTE DOWN SOME OF
THE EXAMPLES THAT SOME OF OUR REALLY IMPORTANT STAKEHOLDERS
UTILIZED IN THEIR EXAMPLES AND I THOUGHT I WOULD JUST BREATHE
LIFE INTO WHAT THOSE SOLUTIONS MEAN.
SO WHAT IT DOES IN ALL PRACTICAL PURPOSES FOR THOSE OF US THAT
HAVE BEEN IN THE MEDICARE INVESTIGATION FIELD FOR
SOMETIME, I CAN SEE WHEN SOMEONE IS BILLING CLAIMS THE MOMENT
THEY ARE ENTERING OUR SYSTEM. I DON'T HAVE TO WAIT ANY LONGER
FOR CLAIMS TO ADJUDICATE TO RUN QUEERIES.
I CAN STILL DO THAT, WHICH IS VERY IMPORTANT TO DEVELOPING THE
MODEL THAT DAVE SPOKE ABOUT, BUT WHAT I CAN SEE NOW IS I WROTE
DOWN A NOTE THAT JENNIFER WOULD HAVE LIKED TO HAVE BEEN ABLE TO
PROVE, A 12 HOUR SAMPLE OF SERVICES.
WHEN WE RAN OUR NATIONAL DATA 18 AND SOME OF OUR GEOGRAPHIC
SPECIFIC DATA THROUGH, WE HAD THERAPISTS THAT WERE VERY BUSY
AND PROVIDING OVER 100 HOURS OF SERVICE IN A 24-HOUR PERIOD.
NOW HOW CAN WE CATCH THAT? HOW CAN WE NOT SEE IT?
IN THE OLD DAYS, MANY OF US ARE RUNNING MANY DATA QUERIES
THROUGH SINGLE DATASETS. SO WE ARE RUNNING A VERSUS B
VERSUS D AND E. WHEN I PERSONALLY AND MANY OF
YOU STARTED MOVING AROUND INTO THE DIFFERENT AREAS OF MEDICARE,
I RECOGNIZED A LOT OF FAMILIAR NAMES THAT WERE BILLING A.
B- AND C, AND E.
THIS SOLUTION NOW INTEGRATES THOSE THREE PROVIDER TYPES AND
NOT ONLY DOES HE IT DO THAT, BUT IT ALSO MOVES FORWARD CLAIMS
BASED ON AB RANT BEHAVIOR THAT IS JUST NOT PHYSICALLY POSSIBLE.
ANOTHER EXAMPLE THAT JOHN USED WAS WHEELCHAIR AND THERAPY.
I CAN NOW SEE A PROVIDER OR SUPPLIER WHO WAS BILLING OVER
100 WHEELCHAIRS A DAY. IT'S IMPOSSIBLE.
AND IT'S OUT THERE. IT DOES TAKE ALL OF US TO SOLVE
THE PROBLEM. I THINK WITH THE VISION AND THE
INVESTMENT OF THE CENTER FOR PROGRAM INTEGRITY, MANY OF US
ARE GOING TO I HAVE A VERY IMPORTANT WEAPON IN OUR ARSENAL.
I CAN TELL YOU THAT THE LAST WEEK OR SO I HAVE BEEN LOOKING
AT THE RESULTS POP UP ON THE TOOL AND I'M NOT GETTING MUCH
SLEEP BECAUSE I CAN'T TURN AWAY FROM MY COMPUTER.
SO WHAT THIS DOES FOR ALL OF US IN REALTIME IT ELIMINATES A LOT
OF THE ACCUMULATION OF DATA AND PRESENTS THE DATA FOR YOU TO
EVALUATE. 19 IT DOESN'T TAKE OUT THE MOST
IMPORTANT PART OF THE EQUATION, WHICH IS YOUR KNOWLEDGE, YOUR
BRAIN, AND YOUR INVESTIGATION, IT JUST ACCELERATES THE DELIVERY
OF SOLUTION. SO JUST TO GO THROUGH A COUPLE
OF THE OTHER POINTS, SOME OF THE OTHER THINGS THAT WE ARE ABLE TO
IDENTIFY WHICH IS VERY IMPORTANT TO ALL OF US, ARE THOSE
PROVIDERS AND I THINK DR. BUDETTI SPOKE ABOUT IT
EARLIER. WE CAN ALSO IDENTIFY THOSE
PROVIDERS THAT MAYBE ON THE LOW END OF THE SCORE THEY NEED
EDUCATION. MAYBE THEY HAVE CODING ERRORS.
MAYBE IT'S JUST MISUSE. WE ARE ABLE TO COUGHER THAT OUT.
ONE OF THE IMPORTANT EFFORTS THAT WE WILL BE PROVIDING IS
THAT DATA BACK TO CMS AND HHS TO PROVIDE IN THEIR TRAINING
EFFORTS AND EDUCATIONAL EFFORTS. THAT'S JUST AS CRITICAL TO ANY
GOOD FRO PREVENTION SOLUTION AS WE MOVE FORWARD IN THIS JOURNEY.
>> THAT WAS GREAT. VERY ENLIGHTENING.
JEFF BREWER IS WITH FICO. JEFF?
>> WE ARE LOOKING AROUND THE ROOM AND THERE ARE SO MANY OF US
HERE AND WE ARE TALKING ABOUT TECHNOLOGY COLLABORATION AND
DATA. AND ALL OF US IN THIS ROOM ARE
ACTUALLY INVESTED IN THAT PROCESS.
SO, IT TAKES -- IT TAKES A VILLAGE.
THIS IS A LARGE VILLAGE SPREAD ACROSS THE COUNTRY.
AND WE ALL HAVE TO STEP AND WE HAVE TO DO THIS.
TECHNOLOGY IS NOT THE ONLY ANSWER.
IT'S A REAL KEY TO THE ANSWER. 20 AS MARY SAID, IT STILL TAKES YOU
TO HELP UNDERSTAND WHAT IS FRAUD?
WHAT IS EDUCATION? WHAT DO WE DO WITH THE
INFORMATION? BUT IT'S BEING ABLE TO FIND OUT
WHICH CLAIMS AND WHICH PROVIDERS WE LOOK AT.
SO I WANT TO FOCUS TODAY TO LOOK AT HOW WE DO COLLABORATE AND
WHAT TYPES OF THINGS THAT MAYBE WE ARE PROVIDING BUT REALLY
WORKING WITH OUR PARTNERS AND OUR CLIENTS AND TYPES OF THINGS
THEY ARE LOOKING FOR AND THE DEMANDS THAT THEY HAVE TO BE
ABLE TO DO THEIR JOBS BETTER. I'LL DO MY 30 SECOND ELEVATOR
SPEECH FOR THE MOST PART. SO YOU KNOW WHO FICO IS.
EVERYBODY HEARS THE WORD ALL THE TIME.
YOU KNOW US AS YOUR CREDIT SCORE.
WE HAVE BEEN DOING THAT FOR CLOSE TO 60 YEARS NOW.
ANOTHER PIECE THAT A LOT OF INDIVIDUALS DO NOT KNOW,
EVERYONE IN THIS ROOM TOUCHES US EVERY DAY IN ONE WAY OR ANOTHER
BY WAY OF CREDIT CARD TRANSACTIONS.
FICO WAS THE PIONEER IN THE CREDIT CARD SPACE.
WE ACTUALLY HANDLED CLOSE TO 90% OF EVERY CREDIT CARD TRANSACTION
IN THE U.S., TRANSLATES TO IN THE 70% GLOBALLY.
SO WE PIONEERED THAT SPACE. EVERY TIME YOU WALK UP TO A
POINT OF SALE, YOU SCAN YOUR CREDIT CARD.
WE ARE LOOKING AND PROFILING YOUR HISTORY, YOUR BEHAVIOR.
DOES THIS LOOK LIKE SOMETHING JEFF HAS DONE BEFORE?
HAS HE EVER BEEN IN TAIWAN BUYING A TV AT 2 A.M.?
HAS HE BEEN AT THE LOCAL GAS 21 STATION ONLY GETTING 4.99 WORTH
OF GAS AND MOVING TO THE NEXT STATION TO TEST HIS CARD?
VERY QUICKLY PROFILING THAT. IN MILLISECONDS, PROVIDING THOSE
RISK SCORES IN REALTIME BACK TO A CRED CARD ISSUER TO MAKE A
DECISION. SHOULD WE PAY JEFF'S
TRANSACTION? SHOULD WE DENY IT?
OR SHOULD WE GET HIM ON THE PHONE TO MAKE THAT DECISION?
DID YOU REALLY BUY THIS? SAME TYPE OF TECHNOLOGY NOW HAS
BEEN BROUGHT INTO HEALTHCARE WHERE WE CAN SCORE A MEDICAL
CLAIM. AND I APPRECIATE WHAT THE FOLKS
ON THIS PANEL ARE TALKING ABOUT AND HOW WE WORK TOGETHER AND THE
FUTURE THAT THE ADMINISTRATION IS TAKING ON MAKING A DIFFERENCE
HERE. SO JUST SO YOU KNOW, THAT'S WHAT
FICO. WE DO REALIZE THAT YOU CAN'T
TAKE CREDIT CARD TECHNOLOGY AND APPLY IT IN HEALTHCARE.
SO WE HAVE HAD TO TAKE THAT WORK WITH OUR PARTNERS AND ACTUALLY
MOLD THAT INTO WORKING WITH A MEDICAL CLAIM.
BEING ABLE TO DO THAT IS EARLY IN THE STREAM AS POSSIBLE.
THIS IS AN OLD SLIDE BUT I THINK IT'S VERY RELEVANT TO BE ABLE TO
SEE THE DIFFERENCES IN VARIOUS INDUSTRIES AND HOW DIFFERENT
TECHNOLOGIES ARE USED AND IDEAS ABOUT FRAUD.
IF YOU LOOK AT CREDIT CARD, WHICH WE HEAR ABOUT ROUTINELY,
IT IS ABOUT A ONE BILLION DOLLAR PIECE OF BUSINESS TODAY.
IT WAS BILLIONS OF DOLLARS IN THE EARLY DAYS.
YOU LOOK AND SEE WHERE IT IS ON HEALTHCARE AND THIS IS SHOWING
100 BILLION DOLLAR PROBLEM. 22 THE PROBLEM IS WE DON'T KNOW IS
IT 50 BILLION, 100 BILLION OR 500 BILLION.
>> WE DON'T KNOW WHAT WE CAN'T SEE.
WE DON'T KNOW HOW BIG AND BAD THE PROBLEM IS.
IT'S A GOOD EXAMPLE TO BE ABLE TO SHOW WHAT ANOTHER INDUSTRY
HAS DONE TO BE ABLE TO CAP THIS. SO CREDIT CARD USING THIS TYPE
OF TECHNOLOGY HAS BEEN ABLE TO CAP THEIR RISK TO UNDERSTAND
WHAT THE RISK IS. SO I THINK IT'S JUST KIND OF
RELEVANT WHEN YOU START LOOKING AT THAT.
ANOTHER THING THAT CREDIT CARD DID IS THEY LOOKED AT
CONSORTIUMS. SO THAT'S SOMETHING THAT WE ARE
LOOKING TO PARTNER WITH, OUR PARTNERS AND WITH THE
ADMINISTRATION. ABOUT HOW DO WE BRING IN ALL OF
THIS DATA AND BE ABLE TO NOT USE HIPPA AS WHAT WAS SUPPOSED TO
HAVE BEEN A GATEWAY FOR US. IT SEEMS AT TIMES TO BE THE
ROADBLOCK TO ACCOMPLISH SOME OF THESE THINGS.
WE SET AROUND A ROOM AND TALK ABOUT THESE VARIOUS CASES AND WE
HAVE GREAT ORGANIZATIONS LIKE NHCAA, ABOUT LET ME TELL YOU THE
FRAUD THAT I FOUND AND THINGS THAT YOU NEED TO START LOOKING
FOR. BUT WHAT DO WE DO ON THE FRONT
END ABOUT TAKING OUR DATA AND FIGURING OUT HOW TO WORK
TOGETHER TO PUT IT IN ONE BUCKET TO BE ABLE TO MINE IT AND BE
ABLE TO PROVIDE RISK SCORES ON IT?
SO WE ARE NOT PUSHING FRAUD OR FRAUDSTERS.
I DON'T LIKE TO CALL THEM FRAUDSTERS ANYMORE.
I LIKE TO CALL THEM FRAUD 23 ENTREPRENEURS.
A FRAUDSTER, YOU CAN GET OUT OF THE BUSINESS.
AN ENTREPRENEUR IS CONSTANTLY LOOKING FOR NEW WAYS TO MAKE
MONEY. THEY WILL PING YOU AND PING YOU
AND PING YOU UNTIL YOU FIND A WAY.
AS YOU CAN SEE, IT TAKES YEARS AND EVEN WHEN WE KNOW THEY ARE
BAD, THEY ARE STILL TRAINING -- DRAINING THE TRUST
FUND. SO WE NEED TO START THINKING
ABOUT THAT AND QUIT PUSHING IT FROM PAYOR TO PAYOR AND THIS
TECHNOLOGY CAN ALLOW YOU TO DO THAT.
JUST A VISUAL HERE. IT'S THE EXPERT.
I KNOW SOME OF YOU IN THE AUDIENCE HAVE SEEN OUR ICEBERGS
BEFORE. IT'S RELEVANT TO SAY WHY
ANALYTICS? IT'S NOT CLAIM EDITING WE ARE TALKING ABOUT.
NOT THE STUFF THAT HAS BEEN DONE TODAY.
IT'S ACTUALLY LOOKING AT THINGS THAT WE CAN SEE.
THE KNOWN VERSUS THE UNKNOWN. I DID DELIVER THIS TO A GROUP OF
DENTAL PROVIDERS ONCE AND THEY THOUGHT IT WAS A MOLAR.
[LAUGHTER] TO ME IT'S AN ICEBERG.
WHARF TOOL YOU WANT TO CALL IT. THAT'S FINE.
BUT ABOVE THE WATERLINE THE LOGIC IS WHAT WE KNOW.
IF WE KNOW IT, WE DO SOMETHING ABOUT IT.
WE WRITE A RULE, WE STOP IT. RULES ARE GOOD IF WE KNOW WHAT
WE ARE LOOKING FOR. IT'S HOW DO WE FOCUS ON THE
THINGS THAT WE DON'T KNOW ABOUT THAT IS DRAINING US?
AND THAT IS WHERE THIS ADVANCED 24 PREDICTIVE TYPE OF TECHNOLOGY
COMES INTO PLAY. SHOW ME WHAT I DON'T KNOW.
WE USE THE TERM, PREDICTIVE ANALYTICS.
I THINK IT'S BECOME AN EVERY DAY CATCHPHRASE.
WHAT DOES THAT MEAN? I THINK ONE OF OUR CLIENTS WHO
IS HERE IN PENNSYLVANIA COINED IT VERY WELL WHEN THEY SAID, IF
I HAVE TO PUT ANYTHING INTO IT TO GET SOME RESULTS OUT, IT'S
NOT PREDICTIVE. I WANT THE DATA TO SHOW ME WHERE
ALL OF THIS INFORMATION AND ALL OF THESE ARE OCCURRING.
DON'T LEAVE HERE TODAY THINKING I SAID RULES ARE BAD.
RULES ARE GOOD. IF YOU KNOW WHERE IT'S AT, WRITE
A RULE, STOP IT. WE WANT TO FIND THE THINGS THAT
A RULE CAN'T CATCH AND YOU DON'T KNOW ABOUT.
SOME OF THE KEY BENEFITS THAT OUR PARTNERS HAVE GUIDED US ON
AND WE WORK TOGETHER WITH THEM ON, IT'S HOW DO WE DETECT MORE?
HOW DO WE DETECT WITH LESS? BUDGETS ARE GETTING CUT.
WE DON'T HAVE ENOUGH PEOPLE. SHOW ME THE WORST CASE SCENARIO.
HIGH DOLLAR? BAD PROVIDERS?
WE FIND A LAYOUT OF FRAUD IN THE DOLLAR RANGE.
WE FIND A LOT OF FRAUD -- THERE IS A LOT OF RESOURCES TO LOOK AT
A DOLLAR. YOU DON'T WANT TO DO THAT IF YOU
CAN SPLICE IT. BUT THOSE DOLLARS ADD UP TO BIG
DOLLARS IF YOU IGNORE THEM. SO MANY ORGANIZATIONS AND OUR
PARTNERS WILL SAY I DON'T HAVE THE TIME OR EFFORT TO LOOK AT
ANYTHING UNDER 10,000 DOLLARS. THERE IS A LOST FRAUD GETTING
CONTEMPLATED AND OCCURRING UNDER 25 10,000 DOLLARS.
THESE FRAUD ENTREPRENEURS KNOW THAT.
WE HAVE GOT TO FIND A WAY AND HAVE TECHNOLOGY TO BE VERY
RAPIDLY VERY QUICK, ONE CLAIM AT A TIME.
SO PRIORITIZE IT. FIND THE UNKNOWN.
AND THEN ONCE YOU SHOW ME WHERE IT'S AT, GIVE ME A SOLUTION THAT
ALLOWS ME TO MANAGE THAT CASE TO BE ABLE TO DRILL DOWN VERY
QUICKLY AS MARY MENTIONED AND UNDERSTANDING BEFORE IT GOES OUT
THE DOOR, HOW MANY OF THESE CLAIMS ARE OUT THERE?
IS THIS A PATTERN WITH A PROVIDER?
IS IT THEIR TRUE PEERS BECAUSE THEY SAY THEY ARE FAMILY
PRACTITIONERS, THEY ARE LOOKING LIKE A PAIN MANAGEMENT.
YOU CAN VERY QUICKLY DO THAT WITH DATA BECAUSE THE DETAILS
ARE IN THE DATA. SO VERY QUICKLY, YOU'RE
PROFILING AND YOU'RE KNOWING WHAT KIND OF PEER THEY REALLY
LOOK LIKE BECAUSE OF HOW THEY SUBMIT THEIR CLAIMS.
SO YOU'RE COMPARING. NOT MESSING WITH THE GOOD
DOCTORS. AND YOU'RE COMPARING THEM TO
THEIR TRUE PEERS TO UNDERSTAND THOSE THAT HAVE QUESTIONABLE
THINGS GOING ON. AND MOVING THIS IS CLOSE TO THE
FRONT END. THEY WANT IT PREPAY.
WE TALK REALTIME. FICO TECHNOLOGY WORKS IN
REALTIME. MILLISECONDS WITH YOUR CREDIT
CARD. WE HOPE ONE DAY HEALTHCARE WILL
CATCH-UP WITH FINANCIAL SERVICES SO WE CAN ALL WORK IN A REALTIME
ENVIRONMENT TO BE ABLE TO 26 ELIMINATE THIS.
BUT THE TECHNOLOGY IS THERE TODAY TO WORK IN REALTIME SHOULD
WE HAVE PARTNERS OUT THERE THAT WANT TO GIVE THAT A TRY.
IT CAN OCCUR. LI SHARE WITH YOU -- WE HAVE
LOCAL NEIGHBORS HERE IN PENNSYLVANIA.
HI MARK USES OUR TECHNOLOGY AND IS GETTING GOOD RESULTS.
AS WELL AS MULTIPLE PAYORS AROUND THE COUNTRY.
WE ARE WORKING WITH STATE MEDICAID.
WE WORK WITH MEDICARE. WE HAVE DONE WORK IN ALL OF
THESE DIFFERENT VENUES SO WE KNOW THAT TECHNOLOGY WORKS.
WE HAVE DONE SOME FORM OF A PILOT TO JUDGE IT AND GET
RESULTS IN EVERY ONE EVER THESE INDUSTRIES.
PENNSYLVANIA HAS BEEN A REALLY GOOD STATE FOR US AND WE
APPRECIATE BEING HERE. VERY QUICKLY, I'LL WIND THIS
DOWN A LITTLE BIT BUT REALLY KIND OF WANT TO SHOW YOU THIS
WHEN YOU START THINKING ABOUT IT.
THERE ARE SO MANY STAKEHOLDERS WITHIN A PAYOR ORGANIZATION AND
THAT PAYOR MEDICARE, MEDICAID COMMERCIAL.
AND IT REALLY BECOMES AN ENTERPRISE-WIDE SOLUTION.
YOU CAN'T JUST FOCUS YOUR EFFORTS IN JUST AN SIU SHOT TO
PAY AND CHASE. YOU CAN'T FOCUS JUST ON CLAIM
EDITING OR JUST ON MEDICAL MANAGEMENT, ET CETERA.
IT HAS TO BE ENTERPRISE YOU CAN PLUG EYE HOLE IMMEDIATELY.
YOU HAVE A BAD POLICY AND ISSUES IN MEDICAL.
ISSUES IN CONTRACT. YOU HAVE GOT PROVIDERS THAT JUST
NEED TO BE EDUCATED ON THE 27 PROPER WAY TO BILL CERTAIN
THINGS. OR INTERNAL TRAINING ON, DON'T
OVERRIDE THESE CLAIMS. A WHOLE LOT OF CLAIMS THAT GET
OVERRIDDEN BECAUSE WE DON'T TAKE THE TIME TO LOOK AT THEM.
SO THERE ARE DIFFERENT AVENUES AND DIFFERENT ASPECTS ALONG WHAT
I CALL THIS CLAIM CONTINUUM THAT GIVES YOU THE OPPORTUNITY TO GET
SOME TYPE OF BENEFIT BACK TO YOU.
WHERE DO YOU WANT TO HIT IT? WE ARE NOW AT I CAN'T RECOLLECT
WORKING WITH ONE PARTNER INDION DATA INTERCHANGE ORGANIZATION
KNOWN AS THE WEBMD BUT THEY ARE THE DATA TRANSACTION HUB BETWEEN
EVERY PROVIDER AND EVERY PAYOR IN THE COUNTRY.
AND WE ARE LOOKING TO FIND OUT HOW CAN WE DO THIS NOW
PREAJUDICATION, BEFORE THE PAYORS EVER GET IT.
AND LAST BUT NOT LEAST, YOU CAN ALWAYS GET WITH ME LATER OR YOU
CAN CALL BUT WE CAN TALK ABOUT SOME OF THE TYPES OF DOLLARS AND
SAVINGS AND SO THIS IS JUST A LITTLE BIT OF A SAMPLING OF A
COUPLE OF OURS FOLKS BUT YOU'RE BEING ABLE TO SEE THESE THREE
BUCKETS, CLAIM LEVEL STUFF, PROVIDER SA.
AND WHAT TYPES OF DOLLARS ON AN INDIVIDUAL CLAIM BASIS, CLAIM
LINE BASIS THAT YOU CAN GET RETURNS ON.
AND THAT IS KIND OF THE WAY WE LOOK AT THAT.
>> FINAL THOUGHTS? >> FINAL THOUGHTS IS I JUST WANT
TO MENTION. WHAT DOES THE FUTURE HOLD?
IT'S REALLY LOOKING AT MORE COLLABORATIONS.
ALL OF US WORKING TOGETHER AND TRYING TO MOVE INTO THESE
CONSORTIUM-TIME OF APPROACHES. 28 WHAT WOULD IT BE LIKE IN
PENNSYLVANIA IF WE HAD ALL OF THE MEDICAID BUSINESS, IF WE HAD
ALL THE COMMERCIAL PAYOR DATA, AND WE HAD ALL THE MEDICARE
DATA? PUT INTO ONE BIG BUCKET?
ANYTHING ELSE WE WOULD BE PUSHING THOSE FRAUD
ENTREPRENEURS OUT OF PENNSYLVANIA TO ANOTHER STATE.
SO THINK ABOUT WHAT THE FUTURE COULD HOLD IF WE COULD DO THAT
NATIONALLY. >> THANK YOU, JEFF.
SO, I DON'T THINK WE'LL HAVE A LOT OF TIME FOR QUESTIONS BUT
JUST DOT WRAP UP. THAT WAS A GREAT OVERVIEW OF THE
ANALYTIC SPACE AND THE DATA SHARING AND CONSORTIUM APPROACH.
THAT'S WHERE WE ARE GOING UNDER THE LEADERSHIP.
THE MESSAGE I WANT YOU TO TAKE FROM THIS IS CMS IS COMING INTO
THIS SPACE. WE ARE COMING IN HARD AND WE ARE
COMING IN FAST AND WE ARE COMING IN BIG.
WE NEED YOUR HELP. THERE IS GOING TO BE BUMPS IN
THE ROAD BUT TOGETHER I KNOW WE WILL MAKE A DENT.
SO THANK YOU TO A GREAT PANEL. [APPLAUSE]
>> WE'RE GOING TO NOW TAKE A FEW MINUTES TO HEAR FROM THE PEOPLE
WHO PARTICIPATED IN ALL OF THE DIFFERENT BREAKOUT SESSIONS.
I KNOW FOR, YOU KNOW, FOR 1/3 OF THE GROUP, YOU WILL HAVE HEARD
ALL THE DISCUSSIONS, BUT LET START OFF.
SO DR. AUGERWALL IS GOING TO TALK ABOUT THE PROVIDER SESSION.
>> THANKS, PETER. I THINK WE HAD A GREAT
CONVERSATION IN THE PROVIDER'S SESSION.
YOU ALWAYS START WITH YOUR BOSS TORQUE DR. BURWICK ACTUALLY
KICKED OFF THE PANEL EMPHASIZING THE PARTNERSHIP AND PARTICULARLY
HERE THE PARTNERSHIP BETWEEN PAYERS AND PROVIDERS, YOU KNOW,
NEEDING TO WORK TOGETHER AND ADDRESS ABUSE AND FRAUD.
HE ESPECIALLY EMPHASIZED AND I THINK THIS IS IMPORTANT TO BRING
OUT NOT ONLY HERE BUT IN AN ONGOING MANNER, IS MUTUAL
RESPECT AND DIALOGUE NEEDED BETWEEN THESE PARTNERS.
THEN HE CONNECTED THE MISSION OF FIGHTING ABUSE AND FRAUD TO THE
CORE MISSION OF CMS AND OTHER PAYERS AND PROVIDERS TO IMPROVE
CARE. FROM THERE, WE WENT TO A BROADER
DISCUSSION ABOUT HITTING MANY TOPICS; PROFESSIONALISM IN CARE,
EMPHASIZING THE PROVIDER RESPONSIBILITY AND PREVENTING,
DETERRING ABUSE AND FRAUD. I THINK THERE WAS A THREAT THAT
CONNECTED THAT TO MEDICAL EDUCATION AND HOW TO ADEQUATELY
BRING IN PHYSICIANS AND TRAINEES INTO A BROADER ETHIC OF
PROFESSIONALISM. A GREAT DISCUSSION ABOUT
COMPLIANCE PROGRAMS AND REALLY VIEWING COMPLIANCE AS AN
OPPORTUNITY FOR PROGRAM IMPROVEMENT, EMPHASIZING
DOCUMENTATION, EVEN SOME REALLY SORT OF A GREAT IDEAS TO GET
PEOPLE EXCITED ABOUT COMPLIANCE AND DOCUMENTATION.
AND, YOU KNOW, I THINK FINALLY, UM, WE DISCUSSED THE BROADER
PICTURE OF FRAUD AND THE NEED TO GET PATIENTS BENEFICIARIES MORE
INVOLVED IN TAKING A PROACTIVE ROLE IN PREVENTING ABUSE AND
FRAUD. I THINK THERE WERE SOME GREAT
AUDIENCE COMMENTS AS WELL. SOME AREAS OF CONCERN THAT ARE
HUGE AND NO DOUBT NEED TO BE LOOKED AT GOING FORWARD.
ONE IS THE TOPIC OF AUDITS. MANY PEOPLE EMPHASIZED THE
NUMBER OF AUDITS T FREQUENCY OF AUDITS AND THE KIND OF STRAINS
THAT PLACES ON PROVIDERS. WE TAKE THAT TO HEART.
EMR, ELECTRONIC HEALTH RECORD AND THE IMPACT THAT THEY CAN
HAVE ON RATES OF ABUSE AND FRAUD.
CODING AND BILLING BEING DIFFICULT TO NAVIGATE, AND, UM,
AND HOW TO EDUCATE AROUND THAT SO PEOPLE BECOME MORE EFFECTIVE
AT THOSE THINGS WITHOUT INTERFERING WITH CARE.
THOSE ARE THE BIG ISSUES THAT CAME OUT.
LOTS OF GREAT QUESTIONS AND DISCUSSIONS BUT PLENTY FOR US TO
WORK ON AS WE HEAD BACK TO BALTIMORE.
THANK YOU. >> TALKING TO US NOW FROM THE
SESSION ON THE ROLE OF PAYERS IS OUR COLLEAGUE FROM DEPARTMENT OF
HEALTH AND HUMAN SERVICES THE ASSOCIATE DEPUTY SECRETARY MARK
MILONSKY. >> THANK YOU.
I ACTUALLY WASN'T EXPECTING TO DO THIS, PETER TWISTED MY ARM
INTO DOING THIS, BUT PETER'S A VERY PERSUASIVE GUY SO I DON'T
MIND DOING IT. I SAT IN ON THE PAYER'S SESSION
AND WHILE WE DISCUSSED A LOT OF THINGS, THE THEME OF THE SESSION
WAS FRUSTRATION, FRUSTRATION IN BRINGING CASE TO A CLOSE.
FRUSTRATIONS IN SHARING INFORMATION AMONG PAYER AND THE
GOVERNMENT AND LAW ENFORCEMENT, FRUSTRATION IN DISPARITY AND
RESOURCES AMONG DIFFERENT PAYERS, BUT BASICALLY THE
FRUSTRATION IS ROOTED IN THE OBSTACLES OF SHARING
INFORMATION, AND THAT'S ACTUALLY ONE OF THE THEMES OF THIS SUM
MYTH. THE THEME BEING THAT WE CREATE
PUBLIC/PRIVATE PARTNERSHIPS BETWEEN LAW ENFORCEMENT,
PROVIDERS, BENEFICIARIES, PAYERS AND EVERYONE ELSE INVOLVED AND
COMMITTED TO FIGHTING HEAL CARE FRAUD.
WE WORK STRATEGICALLY ON LOCAL AND REGIONAL BASIS AND WE FIGURE
OUT A WAY OF GETTING PAST LEGAL OBSTACLES LIKE THE PRIVACY ACT,
CULTURAL OBSTACLES THAT EXIST BETWEEN COMMERCIAL PAYERS AND
PROVIDERS AND BENEFICIARIES, GET EVERYONE WORKING TOGETHER, HAVE
A STANDARD PRACTICE, A WORKING MODEL, AND IF WE CAN SHARE
INFORMATION AND JOIN FORCES, WE CAN DO A FAR MORE BETTER JOB,
AND THE PREDICTED MODELLING CONTRACT YOU HEARD ABOUT TODAY
IS GOING TO BE ONE OF THE PRIMARY TOOLS THAT WILL DRIVE
THIS PARTNERSHIP. I CAN TELL YOU THAT AS A RESULT
OF THIS SUMMIT, WE'RE GOING TO WORK ON PUTTING TOGETHER A
PARTNERSHIP THAT WE HOPE TO ANNOUNCE, UM, WITH
REPRESENTATIVES FROM EACH OF THESE STAKEHOLDERS I MENTIONED,
AND I THINK IT WAS A VERY SUCCESSFUL SESSION.
THANK YOU. >> NOW I'M LOOKING FOR SOMEONE
FROM THE BENEFICIARY SESSION. I DON'T KNOW WHO THE REPORTER
WAS. AWE, GOOD.
I'M AFRAID AIDE HAVE TO REPORT ON A SESSION I DIDN'T ATTEND.
>> I KNOW YOU COULD DO THAT BUT WE WOULDN'T MAKE YOU DO THAT.
WE ACTUALLY HAD A GREAT DISCUSSION LED BY MARY BACH WITH
THE AARP, REBECCA NURIC WHO IS THE DIRECTOR OF THE PENNSYLVANIA
SENIOR MEDICARE PATROL AND JACQUELINE JEFFERS WHO IS
ACTUALLY A VOLUNTEER IN THE SMP PROGRAMS AND WE TALK A LOT ABOUT
THE VALUE OF PARTNERSHIP SINCE WE HAVE BEEN HEARING THROUGHOUT
THE DAY AND WE REALLY FOCUSED ON THE ULTIMATE PARTNERSHIP AND
THAT'S THE PARTNERSHIP THAT WE HAVE WITH BENEFICIARIES.
CRITICAL IMPORTANCE AND THE VALUE OF MAKING SURE
BENEFICIARIES ARE INFORMED, EQUIPPED AND EMPOWERED SO THEY
CAN BECOME ADVOCATES IN THEIR OWN HEALTH CARE ESPECIALLY
TAKING A STANCE BETWEEN HEALTH CARE FRAUD AND ABUSE.
UTILIZING THE SENIOR MEDICARE PATROL PROGRAM DOES JUST THAT
BECAUSE WE'RE ABLE TO PUT PEER WITH PEERS BECAUSE OFTENTIMES WE
KNOW THAT WITH OLDER AMERICANS, SOMETIMES IT'S DIFFICULT FOR
THEM TO TALK ABOUT HEALTH CARE WITH THEIR PROVIDERS SO THEY
HAVE SOMEONE THAT UNDERSTANDS, IT REALLY HELPS THEM TO KNOW
THAT THEY REALLY CAN BE THEIR OWN ADVOCATE.
SO WE HAD A GREAT DISCUSSION ABOUT THE BENEFICIARIES, ABOUT
THE PARTNERSHIPS, AND DEFINITELY ABOUT SHARING INFORMATION AND
MAKING SURE THAT THEY'RE DEFINITELY INFORMED, EQUIPPED
AND EMPOWERED. SO IT WAS GREAT.
THANK YOU. >> THANK YOU VERY MUCH.
IT'S NOW OUR PRIVILEGE TO HEAR FROM ONE OF THE NATION'S LEADING
FRAUD FIGHTERS, SOMEONE WHO HAS, WHO LEADS THE OFFICE OF THE
INSPECTOR GENERAL AT THE DEPARTMENT OF HEALTH AND HUMAN
SERVICES WITH STAFF IN MANY PARTS OF THE COUNTRY AS WELL AS
IN WASHINGTON, AND WHO IS A TIRELESS WORKER IN TERMS OF
CREATING NEW IDEAS AND IN TERMS OF NEW INITIATIVES AND LEADING
ALL OF US IN THE AREA OF FIGHTING HEALTH CARE FRAUD AND
WATCHING VERY CAREFULLY OVER THE WAY THAT THE WAY THE GOVERNMENT
OPERATES AND SPENDS ITS MONEY. MY GREAT PLEASURE TO INTRODUCE
OUR LEADING FRAUD FIGHTER FROM THE OFFICE OF INSPECTOR GENERAL,
THE HONORABLE DAN R. LEVINSON. IF YOU'D ALL WELCOME ME IN
WELCOMING DAN. >> WHAT AN INTRODUCTION.
[APPLAUSE] THANK YOU, THANK YOU, GOOD
AFTERNOON. THANK YOU FOR THAT WONDERFUL
INTRODUCTION, PETER, AND YOU ARE SUCH A WONDERFUL COLLEAGUE TO
JOIN FORCES WITH IN SO MANY RESPECTS IN TERMS OF WHAT WE DO
AND TRY TO ACCOMPLISH. THANK YOU FOR STAYING TO WHAT I
HOPE WILL NOT BE A BITTER END TO THE DAY, BUT WILL BE A SWEET
END, AND I KNOW IT'S FRIDAY AFTERNOON, THERE ARE A NUMBER OF
FOLKS WHO HAVE HAD TO LEAVE FOR ONE REASON OR ANOTHER, BUT THANK
YOU FOR STAYING. I THINK IT WILL BE A SWEET END
BECAUSE I WANT TO GIVE YOU AN ENCOURAGING MESSAGE ABOUT WHAT
WE'RE DOING AND WHAT WE CAN LOOK FORWARD TO, AND IN THAT RESPECT,
I'D LIKE TO BUILD ON MARK SOLONSKY'S MESSAGE IN TERMS OF
THE PUBLIC/PRIVATE PARTNERSHIP, AND I AM SO PLEASED THAT IT WAS
PHILADELPHIA THAT WOUND UP AS THE FRAUD SUMMIT VENUE THAT WAS
GOING TO EMPHASIS, THAT WAS GOING TO FOCUS ON PUBLIC/PRIVATE
PARTNERSHIP AS A SCENE. ONE AMONG THE MANY GREAT
ACHIEVEMENTS IN PHILADELPHIA IS BEING A TREMENDOUS LEADER IN
MEDICINE AND HEALTH CARE. GOING BACK TO BEFORE THE MODERN
ERA OF THE 20th CENTURY IN MEDICINE AND PUBLIC HEALTH,
PHILADELPHIA HAS ALWAYS BEEN A TREMENDOUS LEADER BECAUSE OF THE
PEOPLE IT HAS ATTRACTED AND THE INSTITUTIONS IT HAS DEVELOPED.
PART OF THAT, OF COURSE, IS RIGHT HERE AT THE UNIVERSITY OF
THE SCIENCES IN PHILADELPHIA WITH ITS GREAT HISTORY IN
PHARMACY, IN MANY RESPECTS, PHILADELPHIA IS THE BIRTH PLACE
OF AMERICAN MEDICINE AND IT'S BECAUSE PEOPLE THINK CREATIVELY
AND IMAGINATIVELY IN THIS VERY, VERY IMPORTANT FIELD.
THIS IS ONE MORE AREA WHERE WE NEED TO APPLY CREATIVITY AND
IMAGINATION SO THAT WE CAN ACCOMPLISH IMPORTANT GOALS.
YOU KNOW, FOR THOSE OF YOU WHO HAVE BEEN IN THE FIELD FOR A
WHILE, WHEN YOU HEAR PUBLIC/PRIVATE PARTNERSHIP, YOU
MAY THINK TO YOURSELF, WE'VE BEEN HERE BEFORE.
MY ANSWER TO THAT, MY RESPONSE WOULD BE, I THINK, YES AND NO.
YES IN THE SENSE THAT YOU'LL RECALL THAT IN MID 1990s, THE
HEALTH INSURANCE AFFORDABILITY AND ACCOUNTABILITY ACT, THE
HIPAA LAW MADE IT ONE OF THE CENTRAL FEATURES OF THE LAW WAS
TO PROMOTE PUBLIC/PRIVATE PARTNERSHIPS IN TACKLING HEALTH
CARE FRAUD, AND THAT WAS PART OF THE VERY IMPORTANT HEALTH
CARE/FRAUD CONTROL PROGRAM THAT WAS ESTABLISHED BY THE LAW THAT
OF COURSE IS EXTREMELY IMPORTANT TO US IN THE INSPECTOR GENERAL'S
OFFICE. IF INDEED THE INSPECTOR GENERAL
ACT FROM THE 1970s CAN BE VIEWED AS OUR DECLARATION OF
INDEPENDENT, THE HI PA LAW FROM THE 1990s IS OUR CONSTITUTION.
IT EXPANDED THE RESOURCES THAT WERE AVAILABLE TO OIG IN HEALTH
AND HUMAN SERVICES AND CREATED THIS VERY IMPORTANT PARTNERSHIP
WITH THE JUSTICE DEPARTMENT AND OTHER IMPORTANT COMPONENTS OF
HHS, INCLUDING CMS, WHICH I GUESS AT THE TIME WAS CALLED THE
HEALTH CARE FINANCE ADMINISTRATION, I GUESS.
THAT'S HOW FAR BACK WE'RE GOING, ABOUT A DECADE-AND-A-HALF.
BUT I THINK FOR A NUMBER OF REASONS I WASN'T THERE AT THE
TIME, BUT I WOULD SPECULATE THAT FOR A NUMBER OF REASONS THE
PARTNERSHIP THAT WAS ATTEMPTED THAT BEGAN IN A VERY AGGRESSIVE
AND AFFIRMATIVE WAY ACTUALLY BY A DECLARATION OF PRINCIPLE, BY
THE DEPARTMENT OF JUSTICE THAT WERE PARTNERS, DIDN'T QUITE TAKE
OFF THE WAY I THINK THAT WE REALLY HOPED IT WOULD, AND I
THINK IT HAD TO DO WITH RESOURCES THAT ALTHOUGH OIG
BECAME LARGER AND WE DID HAVE AN ENLARGED PROGRAM AT THAT TIME,
MEDICARE AND MEDICAID COMBINED WERE ABOUT $300 BILLION AND
CONGRESS THOUGHT THAT IT WAS IMPORTANT TO ESTABLISH
INSTITUTIONALLY A MORE POWERFUL VEHICLE TO ATTACK HEALTH CARE
FRAUD AND ABUSE. THOSE DOLLARS NOW ARE RELATIVELY
MODEST COMPARED TO WHAT WE FACE THESE DAYS, BUT THE RESOURCES
DIDN'T REALLY KEEP UP WITH THAT DRAMATIC INCREASE IN BUSINESS,
AND IN TERMS OF WHAT I WOULD CALL ALIGNMENT, THE CHALLENGE OF
BEING ABLE TO ALIGN INTERESTS AND INDEED OUR CHIEF GOAL IS TO
PROTECT THE TRUST FUNDS, AND I THINK IT WAS A CHALLENGE JUST TO
HAVE US ALIGN WITHIN GOVERNMENT EARLY ON, HOW WE WERE GOING TO
ATTACK HEALTH CARE FRAUD AND ABUSE FOR EFFECTIVELY ACROSS
COMPONENT LINES AND DEPARTMENTS AND ACROSS DEPARTMENTAL LINES.
AND IN ADDITION TO RESOURCE CHALLENGES AND ALIGNMENT
QUESTIONS, I THINK TECHNOLOGY EVEN THOUGH 15 YEARS AGO FOR
SOME OF US DOESN'T SEEM THAT LONG AGO, IN TERMS OF
TECHNOLOGY, IT'S PALEOZOIC ERA A LONG, LONG TIME AGO.
THINGS HAVE DRAMATICALLY CHANGED, ESPECIALLY IN THIS
CENTURY OVER THE LAST FEW YEARS AS PEOPLE HAVE REALLY BEEN ABLE
TO ENVISION THROUGH ELECTRONIC HEALTH RECORDS AND
INTEROPERABILITY, MUCH MORE THAN NATIONAL PLATFORM FOR HEALTH
CARE, AND THAT HAS ALL COMBINED TO MAKE THIS ENVIRONMENT AND
THIS EFFORT TO REINVENT MORE EFFECTIVELY THE KIND OF
PUBLIC/PRIVATE PARTNERSHIP THAT WAS BEGINNING TO IMAGINE SOME
YEARS AGO, REALLY VERY, VERY PROMISING.
THERE REALLY IS A BETTER UNDERSTANDING THAT ESPECIALLY IN
HEALTH CARE MOST FRAUDS AFFECT BOTH THE PUBLIC AND PRIVATE
SECTOR, AND INDEED, FOR NOW AND FOR THE INDEFINITE FUTURE, WE
WILL HAVE A HYBRID SYSTEM THAT IS UNIQUE IN THE WORLD.
YOU KNOW, THAT COMBINES SO MANY IMPORTANT POWERFUL PUBLIC AND
PRIVATE SECTOR INTERESTS. THAT'S GOING TO REMAIN IN PLACE
IN SOME FORM AS WE GO FORWARD, AND AS FRAUD REVEALS ITSELF IN
VARIOUS SECTORS, IT REALLY MANIFESTS ITSELF BOTH IN THE
PUBLIC AND PRIVATE SECTOR IN SIMILAR WAYS.
AND THAT REALLY CREATES LESS OF A CLEAR LINE BETWEEN THE PUBLIC
AND THE PRIVATE SECTOR IN HEALTH CARE MUCH MORE SO THAN IN OTHER
PARTS OF THE ECONOMY. SO THERE REALLY IS AN INVITATION
FOR US AS POLICYMAKERS AND AS PRACTITIONERS TO THINK
IMAGINATIVELY ABOUT HOW WE MAKE SURE THAT THOSE DOLLARS, THOSE
VERY CRUCIAL DOLLARS ARE BEING SERVED IN THE RIGHT WAY WHETHER
THEY COME FROM PAYERS OUTSIDE OF THE GOVERNMENT OR WHETHER IT'S
THE GOVERNMENT, WHETHER IT'S THE TAXPAYERS WHO ARE ACTUALLY
FOOTING THE BILL, AND I'M ESPECIALLY PLEASED TO SEE HOW
MUCH MORE ACTIVE WE AS AN OFFICE ARE IN CREATING THAT PARTNERSHIP
NOT JUST IN DEALING WITH PETER AND HIS COLLEAGUES AT CMS AND
AROUND THE DEPARTMENT IN WORKING VERY, VERY EFFECTIVELY WITH THE
JUSTICE DEPARTMENT, AND YOU'VE HEARD FROM TONY WEST AND FROM
THE ATTORNEY GENERAL EARLIER TODAY, BUT ALSO IN REACHING OUT
TO THE NATIONAL HEALTH CARE ANTIFRAUD ASSOCIATION, WORKING
WITH OUR PRIVATE SECTOR PARTNERS IN CREATING A GOVERNMENT/PRIVATE
SECTOR PARTNERSHIP. CERTAINLY WANT TO THANK JENNY
TRESSEL FOR BEING INVOLVED IN THAT ORGANIZATIONALLY.
I THINK THAT'S A VERY, VERY IMPORTANT SIGNAL ABOUT HOW
IMPORTANT IT IS TO US, AND I THANK THE WORKING GROUP THAT IS
BEING FORMED BY US WITH OUR OTHER DEPARTMENTAL COMPONENT AND
THE PRIVATE SECTOR, I THINK, IS A VERY, VERY PROMISING
INITIATIVE, AND THIS IS ALL TO SAY THAT HISTORY
NOTWITHSTANDING, I THINK THAT THIS IS A VERY PROFITIOUS TIME
TO BE THINKING HOW WE BUILD THE PUBLIC/PRIVATE SECTOR
PARTNERSHIP FOR THE 21st CENTURY.
I WANT TO BEFORE SAYING GOOD-BYE, THANK ALL OF OUR FOLKS
IN PHILADELPHIA FOR BEING SO HELPFUL IN PUTTING TOGETHER THE
SUMMIT HERE. AS SOME OF YOU MAY KNOW, WE WERE
HOPING TO DO THE SUMMIT EARLIER IN THE YEAR AND WE NEEDED TO
HAVE IT POSTPONED, BUT THIS IS A TERRIFIC TURNOUT.
THIS IS ALL THAT I CERTAINLY WE HOPED TO HAVE HAPPEN, AND THIS
IS ONE OF A SERIES OF HEALTH CARE FRAUD SUMMITS THAT HAVE
BEEN HELD AROUND THE UNITED STATES.
EACH ONE HAS BEEN, I THINK, VERY, VERY SUCCESSFUL.
EACH BRINGING IT'S OWN COLLECTION OF PANELS THAT HAVE
REALLY ADDED TREMENDOUS PERSPECTIVE TO WHAT IS A
MULTIBILLION DOLLAR CHALLENGE FOR ALL OF US, AND I WANT TO
THANK NICK DEGULIO OF OUR OFFICE FOR HELPING TO ORGANIZE AND FOR
RON CUR WHO WAS ON A PANEL EARLIER.
AND JIM GREER, ALL OF OUR FOLKS, AND OF COURSE TO THANK OUR
GOVERNMENT AND PRIVATE SECTOR PARTNERS FOR BEING SUCH AN
IMPORTANT PART OF IT. I CAN'T LEAVE THE PODIUM WITHOUT
EMPHASIZING HOW IMPORTANT COMPLIANCE PROGRAMS ARE, AND
WHAT I DID IN AN EFFORT TO SHOW HOW PUBLIC/PRIVATE PARTNERSHIP
OBSESSED I AM, TODAY AND IN THE FUTURE, I FOUND A WONDERFUL
CITATION FROM A VERY PROMINENT LAWYER IN THE PRIVATE SECTOR WHO
DOES A LOT OF WORK, ACTUALLY, FOR THE HEALTH INSURANCE
INDUSTRY, AND NOTED IN HIS ONE OF HIS RECENT ARTICLES FOR THE
AMERICAN HEALTH LAWYERS ASSOCIATION, AND HE PUT THIS IN
ITALICS HE THOUGHT IT WAS SO IMPORTANT.
THERE IS NO MORE EFFECTIVE TOOL AGAINST PREVENTING FRAUD AND
DETECTING PROBLEMS EARLY THAN AN EFFECTIVE COMPLIANCE PROGRAM.
AND WHEN IT COMES TO COMPLIANCE, WE DO HAVE ALREADY A VERY RICH
HISTORY IN OIG OF WORKING WITH OUR PRIVATE SECTOR COMPONENTS OF
THE HEALTH CARE INDUSTRY TO PROVIDE COMPLIANCE PROGRAM
GUIDANCE, TO PROVIDE ROUND TABLES, TO CONDUCT CONFERENCES
AND SEMINARS WITH THOUGHT LEADERS ACROSS THE SPECTRUM OF
HEALTH CARE IN COMING UP WITH BETTER WAYS OF CONTROLLING FRAUD
AND ABUSE AND COMING UP ULTIMATELY WITH MORE EFFECTIVE
WAYS OF KEEPING COUNT OF THE DOLLARS SO THAT INDEED THEY GO
TO THE QUALITY HEALTH CARE FOR WHICH THEY ARE INTENDED.
IT'S A VERY RICH AND PROUD TRADITION THAT WE CAN BUILD ON
AND COMPLIANCE IS REALLY GOING TO BE A KEY TO BEING ABLE TO
CONTROL THOSE VERY, VERY PRECIOUS DOLLARS THAT NEED TO BE
ACCOUNTED FOR. SO I THINK AS USUAL, PHILLY IS
SHOWING ITSELF TO BE A LEADER. WE'RE VERY, VERY PLEASED TO BE A
PART OF IT. WE NEED TO REINVEST OURSELVES IN
THE PUBLIC/PRIVATE PARTNERSHIP INITIATIVE, AND THIS IS A
TERRIFIC WAY TO START. THANK YOU VERY MUCH.
[APPLAUSE] >> WELL THANK YOU VERY MUCH, DAN
AS WE KNOW AND WAS MENTIONED EARLIER, WE DO ACKNOWLEDGE AND
APPRECIATE YOUR LEADERSHIP NOT ONLY IN THE COMPLIANCE AREA
WHICH WAS MENTIONED EARLIER, BUT JUST GENERALLY IN THE FIGHT
AGAINST HEALTH CARE FRAUD, AND WE LOOK FORWARD TO CONTINUING TO
WORK CLOSELY WITH THE OFFICE OF INSPECTOR GENERAL AS WELL AS OUR
COLLEAGUES AT THE DEPARTMENT OF JUSTICE GOING FORWARD.
AND THAT'S THE POINT I WANT TO END ON WHICH IS THAT FOR THOSE
OF YOU WHO AREN'T FAMILIAR WITH THE WAY THAT THE DIFFERENT
COMPONENTS OF GOVERNMENT WORK, WHAT YOU'VE SEEN TODAY REALLY
DOES DEMONSTRATE A PUBLIC/PUBLIC PARTNERSHIP AS WELL AS A
PUBLIC/PRIVATE PARTNERSHIP THAT DIFFERENT AGENCIES WITHIN THE
GOVERNMENT, DIFFERENT ENTITIES WITHIN THOSE AGENCIES
RECOGNIZING THE IMPORTANCE OF THIS PROBLEM AND THE NEED TO
COLLABORATE TO SOLVE THAT PROBLEM HAVE VERY EFFECTIVELY
COME TO WORK TOGETHER UNDER THE LEADERSHIP OF THE PRESIDENT AND
THE SECRETARY AND THE ATTORNEY GENERAL.
WE REALLY HAVE A NEW APPROACH TO THINKING ABOUT THE WAY TO SOLVE
THESE PROBLEMS AND A NEW INTERACTION AMONG GOVERNMENT
OFFICIALS AND PROGRAMS WORKING TO SOLVE THESE PROBLEMS.
SO I HOPE YOU'LL TAKE THAT WITH YOU AS ONE OF THE MAJOR POINTS,
REALLY, THAT COMES ACROSS FROM THE WAY THAT WE HAVE APPROACHED
THE FIGHT AGAINST HEALTH CARE FRAUD AND THE NEED TO PREVENT
HEALTH CARE FRAUD, AND IT'S GOING TO TAKE ALL OF US ON THE
PUBLIC SIDE WORKING TOGETHER AND AS DAN LEVINSON JUST SAID, IT'S
GOING TO TAKE A VERY CLOSE WORKING RELATIONSHIP WITH THE
PRIVATE SECTOR WITH ALL OF OUR PARTNERS AND ALL OF OUR
STAKEHOLDERS. SO THANK YOU VERY MUCH FOR YOUR
ATTENTION TODAY AND FOR YOUR PARTICIPATION, AND I WANT YOU TO
KNOW HOW APPRECIATIVE WE ARE OF YOUR INTEREST IN ADDRESSING THIS
WITH US. THANK YOU ALL THE VERY MUCH.
[APPLAUSE] [END OF PROGRAM.]