1/ 28 OCTOBER 2007 / SGS INTERNAL Medicare-Medicaid Network Analysis Jamie Lejcar Andrew Needs Medicare/Medicaid Data Analysis Center

2/ 28 OCTOBER 2008 / SGS INTERNAL Medicare-Medicaid Network Analysis Outline Gap Analysis Integration Statistical Models Provider Profiles

3/ 28 OCTOBER 2007 / SGS INTERNAL Gap Analysis

4/ 28 OCTOBER 2008 / SGS INTERNAL Medicare-Medicaid Network Analysis Medicare –Medicare pays a travel fee for specimen collection in nursing homes. P9603 – Per Mile P9604 – Per Trip Medicaid –Medicaid does not pay a travel fee for specimen collection of nursing home recipients Utilization – Gap Analysis

5/ 28 OCTOBER 2008 / SGS INTERNAL Medicare-Medicaid Network Analysis Utilization – Gap Analysis Medicare –Does not pay: –Very Low Density Lipoprotein (VLDL) CPT – –Lipoprotein CPT – Medicaid –CPT – and are reimbursable in certain circumstances

6/ 28 OCTOBER 2008 / SGS INTERNAL Medicare-Medicaid Network Analysis Utilization Gap Analysis

7/ 28 OCTOBER 2008 / SGS INTERNAL Medicare-Medicaid Network Analysis Utilization Gap Analysis

8/ 28 OCTOBER 2008 / SGS INTERNAL Medicare-Medicaid Network Analysis Utilization - Gap Analysis Look for potential unbundling Multiple Ferritin / Iron tests (82728, and 83540) paid on the same date of service. Glycated Protein (82985) and Glycosylated Hemoglobin (83036) on the same date of service.

9/ 28 OCTOBER 2008 / SGS INTERNAL Medicare-Medicaid Network Analysis Utilization Gap Analysis

10/ 28 OCTOBER 2008 / SGS INTERNAL Medicare-Medicaid Network Analysis Utilization Gap Analysis

11/ 28 OCTOBER 2008 / SGS INTERNAL Medicare-Medicaid Network Analysis Integration of Medicare and Medicaid New York Medicaid Lab Payments –Medicare pays 100% (no co-insurance necessary) –Data integration identifies co-insurance payments in Medicaid –500,000 claims; $4.2 million in potential Medicaid savings

12/ 28 OCTOBER 2008 / SGS INTERNAL Medicare-Medicaid Network Analysis Our Medi-Medi Approach - FUSION Model

13/ 28 OCTOBER 2007 / SGS INTERNAL Integration

14/ 28 OCTOBER 2008 / SGS INTERNAL Medicare-Medicaid Network Analysis Integration of Medi-Medi Data Identify billing aberrancies that can be missed when analyzing only Medicare or Medicaid data –Challenges involved: Crossover Claims –Use of data analysis tools (SAS, JMP, i2, etc.) to identify Medi-Medi aberrancies and networks

15/ 28 OCTOBER 2008 / SGS INTERNAL Medicare-Medicaid Network Analysis Integration Example – Impossible Days

16/ 28 OCTOBER 2008 / SGS INTERNAL Medicare-Medicaid Network Analysis Specific Examples – Provider X Integration Example – Impossible Days

17/ 28 OCTOBER 2007 / SGS INTERNAL Statistical Models

18/ 28 OCTOBER 2008 / SGS INTERNAL Medicare-Medicaid Network Analysis Spike Models Analyzed regularly to detect sudden upward shifts in provider billing and/or paid amounts Can be specific to one provider specialty or many Spikes identified are studied more closely to determine if they are explainable –New provider PIN, legitimate business growth, etc.

19/ 28 OCTOBER 2008 / SGS INTERNAL Medicare-Medicaid Network Analysis Spike Models - Example

20/ 28 OCTOBER 2008 / SGS INTERNAL Medicare-Medicaid Network Analysis Spike Models - Example Lab A –Identified through aberrancies in spike model –Further analysis uncovered additional “red flags”: Referring providers with no rendering claims Claims paid with invalid referring UPIN Billing irregularities with travel codes (P9603, P9604)

21/ 28 OCTOBER 2008 / SGS INTERNAL Medicare-Medicaid Network Analysis Referring Provider Analysis Lab A submitted claims with 443 different referring UPINs in 2006 –Analysis involved matching Lab A’s billing data with each referring provider’s billing data 89 of the 443 (20.1%) referring providers had no billing history for referred beneficiaries $954,234 (54%) of Lab A’s paid dollars stemmed from these 89 non-rendering providers –An additional $119,265 (4.8% of total paid dollars) was paid to Lab A in 2006 on claims with invalid referring UPINs

22/ 28 OCTOBER 2008 / SGS INTERNAL Medicare-Medicaid Network Analysis Referring Provider Analysis

23/ 28 OCTOBER 2008 / SGS INTERNAL Medicare-Medicaid Network Analysis Referring Network Analysis

24/ 28 OCTOBER 2008 / SGS INTERNAL Medicare-Medicaid Network Analysis Travel Procedures For travel reimbursement, Medicare uses procedures P9603 and P9604 –Used when lab employees travel to nursing home for specimen collection Lab employee has to draw specimen –P9603: Billed per mile (greater than 20 miles) –P9604: Billed per trip (less than 20 miles) 2006 Travel Fee Schedule CodeFee P9603$0.94 P9604$12.04

25/ 28 OCTOBER 2008 / SGS INTERNAL Medicare-Medicaid Network Analysis Travel Procedures Unique Locations of Service per Day – Lab A

26/ 28 OCTOBER 2008 / SGS INTERNAL Medicare-Medicaid Network Analysis “Bill and Run” Scheme Scheme: –Providers open a PIN, bill Medicare/Medicaid heavily, then stop suddenly Once spike model detects the spike, provider is gone Need more specialized model to focus on new providers “Bill and Run” model: –Analyzed all PINs opened in a given timeframe –Reviewed monthly billing amounts to detect sudden stops in billing –Added a more real-time approach to fraud detection

27/ 28 OCTOBER 2008 / SGS INTERNAL Medicare-Medicaid Network Analysis Billing Pattern

28/ 28 OCTOBER 2008 / SGS INTERNAL Medicare-Medicaid Network Analysis Provider Profile Report Report summarizes provider’s use of procedure codes –Compares given provider’s usage to his/her peer group (i.e. same specialty) Statistics are calculated to identify potential aberrancies with the provider’s billing patterns

29/ 28 OCTOBER 2008 / SGS INTERNAL Medicare-Medicaid Network Analysis Provider Profile Report Initial figures describe provider’s use of various procedure codes PIN '123456' for 1st Half 2006

30/ 28 OCTOBER 2008 / SGS INTERNAL Medicare-Medicaid Network Analysis Provider Profile Report Ratios are calculated to compare provider to his/her peer group

31/ 28 OCTOBER 2008 / SGS INTERNAL Medicare-Medicaid Network Analysis Provider Profile Report “Z-scores” calculated to determine a standardized difference between provider and peer group

32/ 28 OCTOBER 2008 / SGS INTERNAL Medicare-Medicaid Network Analysis Questions

33/ 28 OCTOBER 2008 / SGS INTERNAL Medicare-Medicaid Network Analysis Contact Information Jamie Lejcar Andrew Needs

34/ 28 OCTOBER 2007 / SGS INTERNAL SafeGuard Services, LLC 5400 Legacy Drive Plano, TX 75024