Healthcare Industry Case Study
Medicaid was having trouble keeping fraudulent doctors and health care providers
off of a big state's pay lists because so many exclusion lists had to be manually
examined and compared. S3's client was concerned their next federal audit would
result in huge fines.
The Crisis:
Medicaid had a problem. A big one, of course. 7 databases. 7 different formats.
And seven different locations. These were lists of names that had to be searched
individually to prevent Medicaid fraud. Available technology was inadequate. The
human process was too slow. Too imprecise. And required too many people.
Exclusion lists had to be scanned. Partial names checked for similarities. Aliases
and addresses needed comparing. A Medicaid enrollment program in a large state demands
automation. And a system that can bring together clean in one place for workers
to search through and work with.
"A Medicaid enrollment program in one of the 5 largest states demands automation."
S3 was asked to automate the process of qualifying applicants to be Medicaid providers.
The challenge involved a complex provider database with extensive data that has
been maintained in two different transactional systems over the past three decades.
Various state and federal agencies maintain lists of people that are excluded from
being named Medicaid providers. Technology shortfalls were causing processors to
search most of these almost manually.
Protocols:
In the past, processors took up to an hour to inspect the exclusion lists and to
enroll a new provider. In addition, because of the human element, they often missed
critical information due to data quality issues within their files. Processors searched
each list manually using the name, common name variants, tax id, and address parts
to find providers on the list. The owners and any associated providers were also
searched in this manner. Identifying providers was made more challenging by the
inconsistent data entry methods and poor data quality methods on each exclusion
list.
"In the past, processors took up to an hour to inspect the exclusion lists and
to enroll a new provider."
Challenge:
The state acknowledged its methodology of processing provider applications and verifying
provider eligibility was time consuming, and that the process introduced opportunities
for error. There was also the risk of penalties to the state caused by mistakenly
enrolling illegal providers. The state simply needed to find a more efficient and
error-proof enrollment process to improve productivity and reduce the risk of penalizations.
Solution:
Using an interactive match on a hosted solution, S3 addressed both provider duplication
and exclusion. S3's proprietary TeraMatch® streamlined the verification of new
applicants seeking to be listed as Medicaid providers. The identification of providers
already enrolled but with duplicate identification numbers was clarified through
reports and workflows. S3 addressed identifying all of the excluded providers by
providing a single interactive, point-of-service match, which compares the provider
data to all of the exclusions lists. And does that at the same time and in the same
place. The system also readily identified previously qualified Medicaid providers
that had been sanctioned, and easily tracked their removal.
"Medicaid simply needed to find a more efficient and error-proof enrollment process
to improve productivity and reduce the risk of penalizations."
Benefits:
By using S3's solution, the state was able to avoid the cost of 7 Full-Time Equivalent
employees per year. And reduce the number of duplicate enrollments. Excluded providers
were more accurately identified and taxpayers were saved several million dollars
per year through increased productivity and risk avoidance. |
|