Transcript HEALTHCARE FRAUD PREVENTION PARTNERSHIP (HFPP) …

HEALTHCARE
FRAUD
PREVENTION
PARTNERSHIP
(HFPP) Overview
June, 2013
For Limited Distribution
The following disclaimer applies: Regarding all Healthcare Fraud Prevention Partnership communications and activities, this is a purely voluntary activity. The committees
regarding data sharing and analysis; information sharing; and the Executive Board, are to be used solely as discussion groups where the individual members can share facts or
information or individual input. No group or consensus advice or recommendations will be given by the partners in the committees or the Executive Board. In addition, no policymaking or decision-making will be performed by the committees or the Executive Board. The Secretary and the Attorney General or their designees will make the final policies or
other decisions.
ENDLESS OPPORTUNITIES…..
Partner #X
Partner #Z
Claims
Compromised
Patient Data
Enhanced
HFPP
Fraudulent
Providers
FraudFighting
Capabilities
Partner #Y
For Limited Distribution
The following disclaimer applies: Regarding all Healthcare Fraud Prevention Partnership communications and activities, this is a purely voluntary activity. The committees regarding data sharing and
analysis; information sharing; and the Executive Board, are to be used solely as discussion groups where the individual members can share facts or information or individual input. No group or consensus
advice or recommendations will be given by the partners in the committees or the Executive Board. In addition, no policy-making or decision-making will be performed by the committees or the Executive
Board. The Secretary and the Attorney General or their designees will make the final policies or other decisions.
PURPOSE OF THE HEALTHCARE FRAUD
PREVENTION PARTNERSHIP (HFPP)
• To exchange facts and information between the public and
private sectors in order to reduce the prevalence of health
care fraud
• To enable members to individually share successful anti-fraud
practices and effective methodologies and strategies for
detecting and preventing health care fraud
• To focus on information sharing in two primary areas:
• Data sharing and analytics
• Outreach, education and information sharing
For Limited Distribution
The following disclaimer applies: Regarding all Healthcare Fraud Prevention Partnership communications and activities, this is a purely voluntary activity. The committees regarding data sharing and
analysis; information sharing; and the Executive Board, are to be used solely as discussion groups where the individual members can share facts or information or individual input. No group or consensus
advice or recommendations will be given by the partners in the committees or the Executive Board. In addition, no policy-making or decision-making will be performed by the committees or the Executive
Board. The Secretary and the Attorney General or their designees will make the final policies or other decisions.
PROGRESS TO DATE
• Officially established by a Charter in fall 2012
• Signed by HHS Secretary Sibelius and US Attorney General Holder
• Members joined from Federal & State government,
private payers and associations
• Created operating structures and processes
• Established legal framework (e.g., MOU)
• Established regular meetings and coordination
• Completion of the First Information Exchange
For Limited Distribution
The following disclaimer applies: Regarding all Healthcare Fraud Prevention Partnership communications and activities, this is a purely voluntary activity. The committees regarding data sharing and
analysis; information sharing; and the Executive Board, are to be used solely as discussion groups where the individual members can share facts or information or individual input. No group or consensus
advice or recommendations will be given by the partners in the committees or the Executive Board. In addition, no policy-making or decision-making will be performed by the committees or the Executive
Board. The Secretary and the Attorney General or their designees will make the final policies or other decisions.
CURRENT PARTNERSHIP AS OF APRIL 1, 2013
Federal Partners
• Department of Health and Human Services, Associate Deputy
Secretary’s Office
• Department of Health and Human Services, Centers for
Medicare and Medicaid Services
• Department of Health and Human Services, Office of the
Inspector General
• Department of Justice, Criminal Division
• Department of Justice, Federal Bureau of Investigations
State Partners
• Arizona Medicaid Office of the Inspector General, Arizona Health
Care Cost Containment System
• New York Office of Medicaid Inspector General
• Iowa Insurance Fraud Bureau (NAIC’s representative on the
Information Sharing Committee)
• Ohio Attorney General’s Office (NAMFCU’s representative on the
Information Sharing Committee)
• Kansas Attorney General’s Office (NAMFCU’s representative on
the Executive Board)
Private Payers
• Aetna
• Amerigroup
• Blue Cross and Blue Shield of Alabama
• Blue Cross and Blue Shield of Louisiana
• Humana
• Independence Blue Cross
• Travelers
• Tufts Health Plan
• United HealthCare
• WellPoint
Associations
• America's Health Insurance Plans (AHIP)
• Blue Cross and Blue Shield Association
(BCBSA)
• Coalition Against Insurance Fraud (CAIF)
• National Association of Insurance
Commissioners (NAIC)
• National Association of Medicaid Directors
(NAMD)
• National Association of Medicaid Fraud Control
Units (NAMFCU)
• National Health Care Anti-Fraud Association
(NHCAA)
• National Insurance Crime Bureau (NICB)
For Limited Distribution
The following disclaimer applies: Regarding all Healthcare Fraud Prevention Partnership communications and activities, this is a purely voluntary activity. The committees regarding data sharing and
analysis; information sharing; and the Executive Board, are to be used solely as discussion groups where the individual members can share facts or information or individual input. No group or consensus
advice or recommendations will be given by the partners in the committees or the Executive Board. In addition, no policy-making or decision-making will be performed by the committees or the Executive
Board. The Secretary and the Attorney General or their designees will make the final policies or other decisions.
Formal
Structures
STRUCTURES OF THE HFPP
Executive Board
Information Sharing Committee
(ISC)
Data Analysis & Review Committee
(DARC)
Studies
Study 1
Study 2
Study 3
Study 4
Study 5
Planning
Teams
Trusted Third Party
Life Cycle
Team
Study
Pipeline
Team
TTP
Strategy
TTP NASA
Challenge
Other
Teams
For Limited Distribution
The following disclaimer applies: Regarding all Healthcare Fraud Prevention Partnership communications and activities, this is a purely voluntary activity. The committees regarding data sharing and
analysis; information sharing; and the Executive Board, are to be used solely as discussion groups where the individual members can share facts or information or individual input. No group or consensus
advice or recommendations will be given by the partners in the committees or the Executive Board. In addition, no policy-making or decision-making will be performed by the committees or the Executive
Board. The Secretary and the Attorney General or their designees will make the final policies or other decisions.
DATA SHARING CONCEPT
• Study Selection
Government
Partner #1
• Design & Planning
• Data Exchange
Private Payer
#1
Private Payer
#2
Trusted
Third
Party
Government
Partner #2
• TRUSTED 3rd PARTY
• Partner Data Analysis &
Actions
Private Payer
#....
• Evaluation
For Limited Distribution
The following disclaimer applies: Regarding all Healthcare Fraud Prevention Partnership communications and activities, this is a purely voluntary activity. The committees regarding data sharing and
analysis; information sharing; and the Executive Board, are to be used solely as discussion groups where the individual members can share facts or information or individual input. No group or consensus
advice or recommendations will be given by the partners in the committees or the Executive Board. In addition, no policy-making or decision-making will be performed by the committees or the Executive
Board. The Secretary and the Attorney General or their designees will make the final policies or other decisions.
ISC – EXTENT OF INFORMATION
SHARING
Each individual HFPP
data exchange study will
be analyzed to determine:
General Public
HFPP Partner
Extensions (e.g.
association
members)
1. What level of data will
reach each level?
2. What products will
reach each level?
HFPP Full
Partnership
3. What special actions or
considerations are
needed for this data
exchange?
Participating Entities
4. How do we measure
success?
For Limited Distribution
The following disclaimer applies: Regarding all Healthcare Fraud Prevention Partnership communications and activities, this is a purely voluntary activity. The committees regarding data sharing and
analysis; information sharing; and the Executive Board, are to be used solely as discussion groups where the individual members can share facts or information or individual input. No group or consensus
advice or recommendations will be given by the partners in the committees or the Executive Board. In addition, no policy-making or decision-making will be performed by the committees or the Executive
Board. The Secretary and the Attorney General or their designees will make the final policies or other decisions.
DARC - CONCEPTUAL STUDY LIFE
CYCLE
Stage: Study
Selection
Stage: Design &
Planning
Stage: Execution
& Analysis
• Study Proposal
• Selection Criteria
• Prioritized into
Pipeline
• Data Design
• Participating Entities
• Planning Logistics
• Moderated Exchange
• Aggregation &
Results
• Analysis
• Corroboration
• Iteration
Stage:
Outcomes
Measurement
• Process &
Operational
• Outcomes
For Limited Distribution
The following disclaimer applies: Regarding all Healthcare Fraud Prevention Partnership communications and activities, this is a purely voluntary activity. The committees regarding data sharing and
analysis; information sharing; and the Executive Board, are to be used solely as discussion groups where the individual members can share facts or information or individual input. No group or consensus
advice or recommendations will be given by the partners in the committees or the Executive Board. In addition, no policy-making or decision-making will be performed by the committees or the Executive
Board. The Secretary and the Attorney General or their designees will make the final policies or other decisions.
DARC STUDY PIPELINE AND OVERLAP
WITH CONCEPTUAL STUDY LIFE CYCLE
Pipeline Tiger Team will:
Document Study Concepts;
Prioritize Concepts;
Recommend Studies.
Stage: Study
Selection
Stage: Design &
Planning
Stage: Execution
& Analysis
Stage: Outcomes
Measurement
• Study Proposal
• Selection Criteria
• Prioritized into Pipeline
• Data Design
• Participating Entities
• Planning Logistics
• Moderated Exchange
• Aggregation & Results
• Analysis
• Corroboration
• Iteration
• Process & Operational
• Outcomes
For Limited Distribution
The following disclaimer applies: Regarding all Healthcare Fraud Prevention Partnership communications and activities, this is a purely voluntary activity. The committees regarding data sharing and
analysis; information sharing; and the Executive Board, are to be used solely as discussion groups where the individual members can share facts or information or individual input. No group or consensus
advice or recommendations will be given by the partners in the committees or the Executive Board. In addition, no policy-making or decision-making will be performed by the committees or the Executive
Board. The Secretary and the Attorney General or their designees will make the final policies or other decisions.
DARC - STUDY PIPELINE AND OVERLAP
WITH CONCEPTUAL STUDY LIFE CYCLE
Pipeline Tiger Team will:
Coordinate Intended Study Concepts with
Technical Sub Groups
Stage: Study
Selection
Stage: Design &
Planning
Stage: Execution
& Analysis
Stage: Outcomes
Measurement
• Study Proposal
• Selection Criteria
• Prioritized into Pipeline
• Data Design
• Participating Entities
• Planning Logistics
• Moderated Exchange
• Aggregation & Results
• Analysis
• Corroboration
• Iteration
• Process & Operational
• Outcomes
For Limited Distribution
The following disclaimer applies: Regarding all Healthcare Fraud Prevention Partnership communications and activities, this is a purely voluntary activity. The committees regarding data sharing and
analysis; information sharing; and the Executive Board, are to be used solely as discussion groups where the individual members can share facts or information or individual input. No group or consensus
advice or recommendations will be given by the partners in the committees or the Executive Board. In addition, no policy-making or decision-making will be performed by the committees or the Executive
Board. The Secretary and the Attorney General or their designees will make the final policies or other decisions.
EARLY ACTIVITIES OF THE
PARTNERSHIP
• The first information exchange has occurred (more information discussed on
the next slide).
• Sharing this information is considered a major milestone in the maturation of
the HFPP and tested the process for data exchange
• Participating partners are evaluating the results for use and value in their
individual programs
• Participating partners were limited due to legal constraints
For Limited Distribution
The following disclaimer applies: Regarding all Healthcare Fraud Prevention Partnership communications and activities, this is a purely voluntary activity. The committees regarding data sharing and
analysis; information sharing; and the Executive Board, are to be used solely as discussion groups where the individual members can share facts or information or individual input. No group or consensus
advice or recommendations will be given by the partners in the committees or the Executive Board. In addition, no policy-making or decision-making will be performed by the committees or the Executive
Board. The Secretary and the Attorney General or their designees will make the final policies or other decisions.
FIRST INFORMATION EXCHANGE
• 11 Partners Contributed
• 2 Federal
• 1 State
• 1 Private Association
• 7 Private Payers
• 3 Information Types
• >1400 Misused
Codes
• >100 Fraud
Schemes
• >44 Data Sources
Fraud
Schemes
Misused
Codes
Data
Sources
First
Information
Exchange
• Partner analysis yielded
various interesting
findings
For Limited Distribution
The following disclaimer applies: Regarding all Healthcare Fraud Prevention Partnership communications and activities, this is a purely voluntary activity. The committees regarding data sharing and
analysis; information sharing; and the Executive Board, are to be used solely as discussion groups where the individual members can share facts or information or individual input. No group or consensus
advice or recommendations will be given by the partners in the committees or the Executive Board. In addition, no policy-making or decision-making will be performed by the committees or the Executive
Board. The Secretary and the Attorney General or their designees will make the final policies or other decisions.
EXAMPLES OF SHARED
INFORMATION: MISUSED CODES &
FRAUD SCHEMES
For Limited Distribution
The following disclaimer applies: Regarding all Healthcare Fraud Prevention Partnership communications and activities, this is a purely voluntary activity. The committees regarding data sharing and
analysis; information sharing; and the Executive Board, are to be used solely as discussion groups where the individual members can share facts or information or individual input. No group or consensus
advice or recommendations will be given by the partners in the committees or the Executive Board. In addition, no policy-making or decision-making will be performed by the committees or the Executive
Board. The Secretary and the Attorney General or their designees will make the final policies or other decisions.
THE FUTURE OF THE PARTNERSHIP
• Build the Trusted Third Party & necessary
technical capabilities
• Active pipeline of studies & data exchanges
• Legal agreements and other necessary policies
• Identifiable data exchanges
• Best practices and information sharing
• Expanded membership & fraud-fighting
capabilities
For Limited Distribution
The following disclaimer applies: Regarding all Healthcare Fraud Prevention Partnership communications and activities, this is a purely voluntary activity. The committees regarding data sharing and
analysis; information sharing; and the Executive Board, are to be used solely as discussion groups where the individual members can share facts or information or individual input. No group or consensus
advice or recommendations will be given by the partners in the committees or the Executive Board. In addition, no policy-making or decision-making will be performed by the committees or the Executive
Board. The Secretary and the Attorney General or their designees will make the final policies or other decisions.
DATA SHARING OPERATIONAL MILESTONES
Business Framework
Technical
Framework
Data
Sharing
CY ‘13 Q1
CY ‘13 Q2
CY ‘13 Q3
CY ‘13 Q4
De-Identified Information Sharing (i.e. Best Practices, Fraud Schemes)
Proof of Concept for Identified Information Exchange
Fully established framework for
identified information exchange
Develop Trusted Third Party
Strategy
Launch Trusted Third Party
Leverage Interim Trusted Third Party
Technical Prototyping
Partner and Participating Entity Framework
 Memoranda of Understanding – Establishes principles of the partnership
 Business Associate Agreements – Legal agreements to allow sharing of identified data
CMS Business Framework
 CMS Delegation of Authority – Authority for CMS to exchange information with private partners
For Limited Distribution
 CMS System of Record Notice – Requirement for aligning CMS systems with data exchange needs
The following disclaimer applies: Regarding all Healthcare Fraud Prevention Partnership communications and activities, this is a purely voluntary activity. The committees regarding data sharing and
 CMS
Reduction
Act Clearance
– Permits
beyond
9 private
analysis; information sharing;
and the Umbrella
Executive Board,Paperwork
are to be used solely
as discussion groups
where the individual
members can expansion
share facts or information
or individual
input. No group or consensus
advice or recommendations will be given by the partners in the committees or the Executive Board. In addition, no policy-making or decision-making will be performed by the committees or the Executive
participating
entities
Board. The Secretary and the Attorney General or their designees will make the final policies or other decisions.
Questions
Questions? Please enter questions into the
Question or Chat pods in the GoToMeeting webinar
interface or please send us an email at:
[email protected]
For Limited Distribution
The following disclaimer applies: Regarding all Healthcare Fraud Prevention Partnership communications and activities, this is a purely voluntary activity. The committees regarding data sharing and
analysis; information sharing; and the Executive Board, are to be used solely as discussion groups where the individual members can share facts or information or individual input. No group or consensus
advice or recommendations will be given by the partners in the committees or the Executive Board. In addition, no policy-making or decision-making will be performed by the committees or the Executive
Board. The Secretary and the Attorney General or their designees will make the final policies or other decisions.