Program Integrity Case Management
Jul 27, 2015
Program Integrity
Case Management
Analytics to Identify
Providers or Claims for
ReviewRetrospective Claims Editing
to Identify Overpayments
Claims Auditing
Overpayment Recovery
Provider Education
Feedback to Policies and
Systems
Investigate Fraud
Referrals
Medicaid Audit Lifecycle
3
How can Program Integrity staff effectively manage audit findings, recoveries, and provider communication?
Challenge
eSante™ ARMS™ allows organizations to: • Automate investigations
• Analyze multiple data sources with cross-dimensional analytics and rich visualization tools
• Create repeatable, auditable, defensible and recoverable investigative processes
• Control access to and custody of sensitive information
• Customize dashboards for different stakeholder roles
• Publish findings that comply with legal, regulatory and industry reporting standards
• Reduce time and cost of investigations
Supports All Program Integrity Business Processes
5
Identify Vulnerabilities
• Review claims• Analyze patterns• Identify schemes• Detect Transactions• Estimate exposure• Probe weaknesses
Evaluate Workload
• Approve pursuits• Determine/apply threshold
• Determine extrapolation, sampling
Conduct Remediation
• Assign investigation cases
• Audit cases• Enforce compliance
Manage Recoveries
•Generate demand letters
•Reconcile remittance
•Update A/R
Process Appeals
•Log appeal•Resolve appeal
Fully Modeled
Investigation Command & Control
Results: • Rapid identification and
processing of improper payments
• Better understanding of cause for improper payments
• Up-to-date/quality provider data
• Streamlined communications to providers and payer agencies
Reports
Workflow
Better organized
• Suspected fraud cases well documented and qualified
Demonstration
•Dashboard of Case Activity
•Review Case
•Attach chart
•Recovery
•RAC Reports