Digital transformation in healthcare extends beyond the clinic. This can be leveraged to maintain and fortify the integrity of healthcare programs such as Medicaid. Through the advanced use of contextualized data, healthcare entities can transform operational processes to improve efficiencies, drive positive outcomes in population health, all while combatting fraud, waste and abuse.
So how can you protect the integrity of your Medicaid program? The answer is simple – by leveraging data effectively. In this article, we’re breaking down the top benefits of using your data to ensure your Medicaid payer program is as effective as possible.
Benefit #1: Reduce Costs
Using data effectively in your Medicaid program can uncover significant cost-savings opportunities. Analyzing claims data alongside additional data sources can provide a comprehensive understanding of cost expenditures across patient and provider populations and individual patient levels. Implementing robust data analytics in your Medicaid program can also lead to substantial long-term savings. By identifying and addressing suboptimal patterns early, you can prevent the accumulation of improper payments and reduce the financial burden on the system.
With improved data analysis and visibility, you’ll achieve a higher level of awareness of potential fraud, waste and abuse among providers and recipients. You can use data analytics to recognize patterns and anomalies and uncover areas of concern such as improper payments in pharmacy and recipient fraud or fraudulently coded billing statements. Utilizing data effectively enables data-led process improvement and proper evidence to afford Medicaid programs the ability to strengthen resource recovery initiatives, reducing overall time spent and cost of investigations.
Benefit #2: Improve Services
By leveraging data analytics, you gain a comprehensive understanding of resource utilization for Medicaid populations. Integrating fee-for-service pharmacy and service claims, managed care encounters and enrollment data provides invaluable insights into the efficacy of care delivery services. This holistic view allows you to optimize resource allocation and improve overall service quality.
Insight into your Medicaid population can extend past Medicaid services as well – advanced data analysis can provide a glimpse into utilization of other means-tested benefits such as Temporary Assistance for Needy Families (TANF) and Supplemental Nutrition Assistance Program (SNAP). This allows you to better understand recipient needs and tailor Medicaid services accordingly. By identifying gaps in care or overlapping services, you can streamline benefit delivery and improve outcomes for vulnerable populations.
Benefit #3: Prioritize and Improve Processes
When it comes to program integrity, inefficient and inconsistent processes quickly degrade the success and efficacy of your program. But what are you to do when you don’t know where to start? Start with the data. Data drives efficient decision-making – from improving analytics algorithms, models and scoring to streamlining operations and maximizing resources leads to effective prioritization and process improvement.
Data intelligence allows Medicaid programs to quickly and accurately prioritize specific communications with patients and providers. Visibility and accessibility to advanced criteria allows you to segment your audience and take individualized actions that support favorable action and outcomes. This approach not only improves engagement but helps ensure compliance and reduces the risk of fraud.
Benefit #4: Uncover Outliers and Anomalies
As you continue the task of identifying fraud, waste and abuse to maintain Medicaid program integrity, access to data intelligence proves invaluable in pinpointing new opportunities for investigation and recovery. By analyzing patterns in Medicaid claims data, you can quickly identify outliers, anomalies and suspicious activities. This allows you to build evidence-based processes versus traditional manual analysis for comprehensive and efficient results.
Traditional audit procedures require manual analysis of large expenditures, claim volume patterns or insider tips to drive targeting. Advanced data analytics provides a different view. Using data effectively, healthcare organizations can investigate by deploying multiple investigative methods, cross-referencing various data points such as relationships among providers, pharmacies, and recipiences; comparisons of diagnoses and drug use; and geographical considerations. This allows healthcare organizations to uncover patterns and relationships otherwise unnoticed.
This expanded interaction with data allows auditors and analysts to utilize their time more productively. Rather than waiting for a specific query or report to confirm their investigative intuition, with an analytics solution like Salient Health, they can interactively explore and pursue possible patterns of fraud on their own.
Data and Medicaid Program Integrity in Action
Spurred by news reports of a raid yielding numerous arrests for sale of prescription drugs, one state Medicaid investigator used Salient Health to examine beyond the names of the arrested individuals to look at all oxycodone prescriptions by county in her . She discovered the county where the raid occurred, with a population of less than 500,000 people, was number one in the state in terms of Medicaid-paid oxycodone.
Total Medicaid spending on oxycodone in that county increased over 100% from 2008 to 2010 and the number of pills nearly tripled in the same period.
With a few clicks, the investigator leveraged the Salient Health platform to generate a complete list of providers writing oxycodone prescriptions in that county—and ranked them by number of prescriptions, pills dispensed, dollar value of claims, and more.
The investigator uncovered additional targets to investigate and ultimately reduced the oxycodone fraud further.
As technology continues to evolve, the need to use data to effect change and ensure Medicaid program integrity is more important than ever. Agencies that invest in data analytics capabilities now will be better positioned to protect program dollars and ensure proper care for beneficiaries.
Embracing a data-centric approach can maintain public trust in the Medicaid system while creating more resilient Medicaid programs. Implementing robust data analytics systems can detect fraud and abuse more efficiently, reduce improper payments and ensure resources are used appropriately. Data-driven approaches not only save money but improve the quality of care for beneficiaries. The journey toward optimal Medicaid program integrity is ongoing, but with access to the right data, strategic, significant progress is within reach.
