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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

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tha october 21 2009 data mining panel discussion talking points

THA – October 21, 2009Data-Mining Panel DiscussionTalking 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

slide2
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

slide3
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
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.