NAMPI Quarterly Newsletter
May 2024 – Volume 9
NAMPI 2024 Annual Conference
Join us in New Orleans! We will be announcing our agenda shortly and look forward to coming together in August. Register soon to take advantage of Early Bird rates. Learn more here.
Challenges and Solutions: Highlights from the Southeast
Greetings NAMPI Colleagues,
Spring has sprung here in the southeast region and just like a beautiful springtime we are gathering new issues like flowers amongst the different states here. As with any region, the southeast has a variety of happenings and issues, and we want to highlight a few of them for you in this issue of the NAMPI Newsletter.
Jennifer Dudinskie, the PI Director from Kentucky, shared that they are in the process of onboarding their new MMIS system. It is called MCAFS (Medicaid Claims and Automated Financial Solution), which will go live later this year. Their current system has been in place for over 20 years and they are very excited about the new possibilities this will bring, especially in terms of tracking provider suspensions with a better solution to linking providers, owners, and rendering providers to cut down on billing/claim issues during investigations.
Additionally, they have partnered with the Office of Data Analytics (ODA) team to create a dashboard and algorithm process for better auditing. They are very excited to have this up and running and are starting to explore the possibilities of stronger and better auditing, especially since they do not have a recovery audit contractor.
Michael Targia, the PI Director from South Carolina, indicated that South Carolina recently initiated the process of sending verification letters to rendering providers, aiming to uncover any instances of unauthorized use of their provider information. Each letter lists the billing providers using their NPI and includes summary measures for the associated claims. Rendering providers are requested to validate their association with all listed billing providers and confirm the provision of services within the specified date ranges outlined in the summary. So far, South Carolina has used these verification letters to target high-risk specialties such as behavioral health, resulting in fruitful leads for further investigation. We can’t wait to hear how the rest of this project turns out, maybe it will be a presentation at NAMPI in 2025.
Patrick Piggott, Associate Director of Investigations from North Carolina, talked about how they have partnered with Peraton / UPIC vendor to move forward with audit work on self-directed personal care and other In-home care under the Capitation-Children (CAP-C) and Capitation-Disable Adults (CAP-DA), and Innovations Waiver (I/DD). We believe that this work will further inform the State on potential risks to the NC Medicaid program for Self-Directed Services and offer risk mitigation strategies to improve overall compliance, reduce policies gaps, and reduce improper payments. We also aim to move forward on collecting any overpayments identified.
This author is from Florida, and we have a lot going on here. We too have been working on our new MMIS transition, though there is another article in this newsletter about that though, so I will share about something else we have been working on. Our team has noticed that providers who are going to be terminated have owners that “slide-in” to ownership of other providers, effectively avoiding their ownership in the Medicaid program being fully terminated. This may be a small percentage of ownership and this change is generally in process while a termination is being processed. This allows an individual to continue gaining income from the Medicaid program while being terminated from the Medicaid program for potentially egregious reasons that may not have risen to the level of a for cause termination. We are reviewing this issue and making a policy recommendation. For now, we do review active providers linked to terminated providers as frequently as possible to mitigate this issue. We hope to resolve it on the forefront of the issue.
As you can see, the southeast is hard at work as we know the rest of the country and our territories are. If you have any questions regarding these issues, please reach out to any one of us, we will be happy to discuss in further detail. Jennifer’s email address is Jennifer.Dudinskie@ky.gov, Michael’s email address is Michael.Targia@scdhhs.gov, Patrick’s email address is patrick.piggott@dhhs.nc.gov and my email address is ann.kaperak@ahca.myflorida.com.
Still Reppin’
– Submitted by Dale Carr, Chairperson of the NAMPI Regional Representatives
I hope this newsletter finds all of you doing well. Spring has sprung here in Missouri and
everything is as green as Ireland. Hopefully, Old Man Winter has left your area and
things are warming up.
As I write this article, the NAMPI Board and ARB (the group that helps plan our
conferences and webinars) are excited to be going through the many proposals that were
submitted for sessions at our upcoming annual conference in August. It seemed like
we started a little slow on submissions, but we were pleasantly overwhelmed
with proposals during the final week. I believe we had about 40-something submissions
from the states and our federal partners at OIG and CMS. There was another group
submitted by vendors who are sponsoring various parts of the annual conference.
I want to give a big shout-out to our NAMPI Regional Representatives around the
country who worked with the states in their areas to solicit the many quality session
proposals. We asked and they came through big time.
We are looking forward to another great conference in New Orleans this year. The
NAMPI Board had the opportunity to visit the conference hotel and check everything
out. The hotel and meeting spaces are great and there are so many things to do in New
Orleans afterhours.
NAMPI is extending a scholarship to each State and U.S. territory, so please take
advantage of those. It would be fantastic to have representatives with Medicaid
program integrity from every State and territory attend the conference.
There will be elections this year for the NAMPI Board positions. There will be
information in another part of this newsletter about the eligibility requirements and
nomination process.
There are also some new Advisory Board Member positions to be filled. Those
positions and my position as the Chairperson of the Regional Representatives are
appointed by the NAMPI President. Regardless if you’re interested in an elected or
appointed position, the best place to start is by letting your Regional Representative
know of your interest and filling out the Application/Request for Nomination Form.
There are several other ways to contribute to NAMPI including serving on one of
several standing committees on training, improving the NAMPI member portal, etc., or
by helping at the annual conference by serving as a moderator for a Fraud Side chat or
break out session.
I’m looking forward to seeing everyone at the conference in New Orleans in August. I
know it’s going to be a great conference with a lot of quality content, regardless of
whether you attend in-person or virtually. We hope it is in-person! And as always, we
will announce our 2025 location at the conclusion of our annual conference.
Thank all of you for all you do to protect the integrity of the Medicaid program.
Best regards – Dale
A Program Integrity Perspective on Major Changes in Medicaid Systems Development
– Submitted by Ann Kaperak, Florida Agency for Health Care Administration
It’s been over 10 years now since Florida Medicaid started the process to reprocure its Medicaid Management Information System (MMIS). What started as a standard fiscal agent changeover process has long since evolved into the more modernized, CMS-approved, “module” approach with a new fancy name — Florida Health Care Connections (FX). Throughout this process we (Program Integrity) have been deeply involved with the intent of keeping program integrity concepts at the forefront of each step along the way.
Below is a graphic of the process, which is described in summary fashion (and to the extent relevant from our perspective to our PI partners) following the graphic.
The first step in our state’s process was to procure an Independent Validation and Verification (IV&V) contractor. Their job is to ensure that each vendor that is brought on throughout the rest of the process is doing what they are called to do in this project and that the Agency, and other stakeholders are keeping their word as well. After that procurement, the process proceeded like everything does in Medicaid, with a submission of a plan to CMS for their approval. Once the plan was approved by CMS, another vendor was procured. This vendor is called the Strategic Enterprise Advisory Services (SEAS) vendor. Their job is to speak with the Agency and stakeholders to ensure continuity, to understand and strive to maintain the procurement standards, to plan and document every step of the way, and to work with everyone across all the vendors to achieve consistency. Ultimately that process, the work of the SEAS vendor, if done correctly, can take years to complete.
From a program integrity standpoint, some recommendations if your state is heading in this direction:
- Be patient – it’s going to be a long process.
- Be vocal – don’t just assume it will be the same old, same old…speak, do your homework and be ready at meetings, and voice concerns when you have them. Don’t let PI get muted through the voluminous processes.
- Be vigilant – it can be daunting. We have been through leadership changes, contractor changes, and many other types of changes. Sometimes it seems like we keep starting over. It is exhausting at times to feel like you are just repeating yourselves to new vendors or the same vendors but new personnel. Keep speaking up repeatedly.
From a program integrity standpoint, it has been demanding to make sure our needs are clearly conveyed and maintained at the forefront of all of the requirements documents for each of these modules then carried through to implementation.
The first module to go live in Florida is the Enterprise Data Warehouse (EDW). The Agency’s vendor for this module is Deloitte. Over the last 3 years we have worked with them through contract validation with the SEAS and IV&V vendors as well as subject matter experts from other areas in the Agency and with the FX team taking the lead. It has a been a long process that has demanded many of our resources. We have also worked with them on conceptualizing what we need to have better to succeed in program integrity for reporting purposes, on dashboards that will provide leads to our teams. In the process of developing the EDW the program integrity team participated in no less than 350 meetings over the span of three (3) years to ensure that we were working toward having the data necessary data support an audit of a provider or a law enforcement referral. This included validation meetings, joint application development meetings, a variety of documentation reviews, user acceptance testing and participating in the first part of our certification process with CMS and MITRE.
Tip: If you are doing these types of procurements, if you don’t invest the time and resources to develop the system, and if you don’t speak up to insist on what you need, you won’t end up with a resource that has program integrity in mind.
We continue now to partner with our FX office (that is a newly created organization unit in our Agency – dedicated to ensuring success on this massive project) on the next modules, including the provider services module. As everyone reading this knows, providers are vastly important to what we do. We are working with our provider enrollment team and the vendor as well as other stakeholders to improve safeguards and instill technology that was not available previously for the application and credentialing process. This module will also leverage the Unified Operations Center (UOC) which coordinates communication for recipients and providers as well as other external individuals. It is at the UOC where our new complaint center will be for the Agency. The complaints will be for general Medicaid information, licensure, health plan questions and Medicaid Fraud and Abuse. This will really be a center for everything.
Tip: In case you haven’t heard this message loud and clear – speak up and be vigilant. Sometimes we find ourselves in these many meetings wondering why nobody else is telling the vendor that they didn’t get it right – you can’t rely on any other office or contractor to ensure that the program integrity needs are being met. If you don’t show up prepared and willing to speak up you won’t get your needs met!
There are, as you can see in the chart above, many other functions (modules) are coming along in the process. We have the core system and a pharmacy benefits manager (PBM) to be worked on as well, the great thing about the modular system is that with the Integration Services/Integration Platform (IS/IP) vendor, you can add as many additional modules as we see fit for your needs.
Tip: Work closely with your other offices (within your agency) to develop the relationship you need to ensure that others will rally and fight for the needs of program integrity alongside you.
Recently our FX team spoke at the 2024 Healthcare IT Connect conference about this project and with other states and their successes as well. From a program integrity perspective, we value our partnership with our internal partners, the FX team, the vendors that listen to our experiences and implement products that are useful to our needs as customers so that we can continue to be successful in our identification of recoveries and referrals.
If any other states are doing the modularize approach to MMIS procurement (or have already completed it or are just now considering it), please add your thoughts and help us continue the conversation in the State-Only Forum.
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