FOR IMMEDIATE RELEASE: February 3, 2016
FOR MORE INFORMATION: Jeff Van Ness, (202) 204-7515
NEW REPORT HIGHLIGHTS SAFETY NET HEALTH PLAN EFFORTS TO PROMOTE PROGRAM INTEGRITY IN MEDICAID
WASHINGTON—A new report issued today by the Association for Community Affiliated Plans (ACAP) examines ways in which Safety Net Health Plans work to promote program integrity in Medicaid. The report, which was written with support from Verisk Health, an ACAP Preferred Vendor, highlights strategies employed by plans to prevent, detect and resolve fraudulent or wasteful activities.
Federal estimates put the improper payment rate for Medicaid at 9.45 percent for Fiscal Year 2015. This means payments were sent to the wrong recipient, were for the wrong amount, lacked documentation, or were used in an improper manner. Most of these errors arose from fee-for-service programs and eligibility determinations. In stark contrast, the improper payment rate in Medicaid managed care was far, far lower: an estimated 0.12 percent.
“Safety Net Health Plans take their stewardship of public funds very seriously,” said ACAP CEO Margaret A. Murray. “They provide extensive training to their staff, partner with other plans and law enforcement agencies, and perform extensive data analysis to assure that the right payment is going to the right provider. And I’d stress here that the overwhelming majority of physicians in our plans’ networks work hard and honestly to deliver the very best care.”
The profiled activities include data analysis and claims review to identify aberrant claims patterns; the targeted use of Explanation of Benefit documents to alert members to help assure that billed services were actually delivered; partnership with regulators, law enforcement agencies and other health plans; employee training; and efforts to reduce avoidable adverse events such as hospital-acquired infections.
The paper also highlights a nationwide collaboration to pool data to proactively identify transactions as suspicious. Verisk Health’s Pooled Data Alliance is used by health plans to analyze claims against a database of claims representing tens of millions of lives from insurers from across the country. This helps plans to identify aberrant behavior that may not be detected in individual data sets, such as providers who bill for more than 24 hours in a day.
The paper is available in full on ACAP’s Web site at www.communityplans.net.
ACAP represents 57 not-for-profit Safety Net Health Plans, which provide health coverage to more than fifteen million people in 26 states. Safety Net Health Plans serve their members through Medicaid, Medicare, the Children’s Health Insurance Program (CHIP), the Marketplace and other health programs. For more information, visit www.communityplans.net.
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