Health Information Exchange Conference of Western Attorneys’ General July 19, 2010

Sandlot, LLC  A regional Health Information Exchange (HIE) connecting North Texas physicians, hospitals, and other healthcare providers.  ∙ 1.4 million patients  ∙ 1,400 physicians and staff trained  ∙ 350+ physicians feeding electronic clinical data  ∙ 7 connected North Texas hospitals  ∙ 50,000 clinical transactions per day

What Sandlot Does  1. Takes an Electronic Medical Record (EMR), which is a document electronically created during a physician/patient visit.  2. Incorporates that new EMR into the patient’s Electronic Health Record (EHR), which is the patient’s medical history.  3. Does this in real time and in a fashion that is parsable across disparate systems and interoperable with various EMR data sources.  4. Ensures the EMR and EHR can be displayed for providers throughout the community at the point of care.

LEWIS MORRIS Chief Counsel to the inspector general U.S. Dept. of Health and Human Services June, 2010 “Right now it’s a good bet that you can take millions from [HHS], and chances are, you’re not going to get caught.”

JAMES BUCHANAN Head of White-Collar Fraud U.S. Attorney’s Office - Houston April, 2010 “[Medicaid] is easy to steal from. I think we’ve made a dent but this is a very target-rich environment.”

TIM DELANEY FBI Head of White-Collar Crime Miami, 2007 “[Medicaid fraud] is a field where you can be a relatively recent immigrant new to America and not know anything about the healthcare system and open up your company and start billing.”

Current System  ∙ Dated - not digitized.  ∙ Think about law school, pre-Westlaw versus ease of researching and intelligence gathering in  ∙ Incredible opportunity to improve efficiency, identify inaccurate and improper billings, scan for fraud and reduce paper waste.

No Internal Innovation or Controls  ∙ Biggest innovation has been to add incentives for whistleblowers.  ∙ Harsher penalties – but only if the criminal is caught.  ∙ Not much prevents criminals from succeeding because the auditing and tracking is enormously out of balance with resources allocated to Medicaid Fraud Control Units.

Medicaid Fraud Control Units (MCFUs)  ∙ Federally subsidized independent watchdog groups which are normally housed in the state AG’s offices.  ∙ 2008: 1,851 staff members and received $184 million in federal support.

MFCU Convictions and Recovery  ∙ 1997: 871 Cons, $ 147 million  ∙ 2003: 1,096 Cons, $ 268 million  ∙ 2008: 1,314 Cons, $ 1.3 billion

Georgia MFCU  ∙ Georgia has a successful HIE.  ∙ The increased the use of data analysis to assist Georgia’s MFCU in tracking fraud has increased the state’s recovery number by $10 million in two years.  ∙ From $16 million in 2007, to $26 million in 2009.

10 th Circuit Ruling  ∙ Becker v. Kroll 494 F.3d 904, C.A.10 (2007)  ∙ MFCU search and seizure case.  ∙ Court views search and seizure narrowly, saying search was constitutional, precedent for MFCUs to have broad authority to search medical records.

2 nd Circuit Ruling  ∙ U.S. v. Singh 390 F.3d 168, C.A.2 (2004)  ∙ MCFU search and seizure case.  ∙ Court relies on the good faith exception to probable cause concerning the search warrant.

7 th Circuit Ruling  ∙ U.S. v. Nechy 827 F.2d 1161, C.A.7 (1987)  ∙ Search of pharmacy.  ∙ “…if a search is objectively reasonable, the motives of the officers conducting it will not turn it into a violation of the Fourth Amendment.”

Recommendations  ∙ Consider mandating e-prescribe in your states.  ∙ Consider mandating that Medicaid providers participate in a Health Information Exchange solution.

Job Creation  ∙ Data Liaisons  Explain and interpret findings  ∙ Data Miners  Provide information to liaisons  ∙ Tech Support  Keep the system functioning properly

3 Click Solutions  ∙ Kymber Messersmith  ∙  ∙  ∙ Alex Buckley  ∙  ∙