MediStrategy Ep 09 - Bill Lucia of HMS on Medicaid Program Integrity

MediStrategy with Kip Piper Episode 09: 

Fighting Healthcare Fraud and Ensuring Medicaid Program Integrity: Interview with Bill Lucia, Chairman and CEO, HMS

Summary

“Fighting health care fraud is like playing Whac-A-Mole.”

Our nation’s $3.2 trillion healthcare system is a complex beast. To ensure its integrity, we must combat a range of issues – from unintentional errors to criminal activity. Today’s guest is an industry leader in leveraging data analytics and the benefit of a national perspective to identify bad actors and ensure that Medicaid is the ‘payer of last resort.’

Bill Lucia is Chairman and CEO of HMS Holdings, the nation’s largest and most successful company dedicated to providing the broadest range of healthcare cost containment solutions to help purchasers, plans, and at-risk providers improve performance. HMS works with 45 state Medicaid programs, 250 health plans, Medicare, large employers, and provider organizations to help contain costs and protect our nation’s healthcare system from fraud, waste, and abuse.

Lucia joined HMS in 1996, becoming chairman, president, and CEO in 2009. He is responsible for leading HMS through the evolving healthcare landscape, demonstrating the ability to formulate and implement key strategic initiatives.

Today he shares HMS’s holistic approach to safeguarding the integrity of the $590 billion Medicaid program via technology, know-how, and advanced analytics. Listen and learn about HMS’s pioneering work in the areas of fraud detection, overpayment recovery, and coordination of benefits as well as the organization’s policy recommendations for Medicaid reform.

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Topics Covered

The mission of ensuring the integrity of nation’s healthcare system by reducing costs and removing fraud, waste, and abuse.

The complex nature of the Medicaid system:

• $590 billion program
• Over 1 in 4 Americans enrolled in either Medicaid or CHIP (77 million in Medicaid and 6 million in CHIP)
• Covers more types of services and providers than Medicare or any private insurer
• Serves the most clinically and demographically diverse and most vulnerable, highest cost populations
• Constantly changing

How HMS works to ensure program integrity in Medicaid:

• Verify that claims paid by appropriate party (coordination of benefits, third-party liability)
• Confirm that claims are paid accurately (billed appropriately, medically necessary services, no errors related to policy)

How technology, know-how, and analytics are used to:

• Identify providers with a propensity for incorrect billing
• Recognize program rules that cause errors
• Anticipate potentially fraudulent activity

How pattern recognition is used to detect inaccuracies and fraud in claims: 

• Unintentional errors in billings to Medicaid and commercial health plans)
• Fraud such as billing in excess of 24 hours/day, 230 days/year

The significant return on investment from HMS program integrity work:

• Over $1B in taxpayer dollars recovered annually
• Far more saved through cost avoidance
• 90% of their work is done on contingency
• Average return on investment (ROI) is 15:1
• One state reported 900% ROI

How to make the case for preventative measures (vs. recovery dollars):

• States always looking to rein in costs and balance budget
• Keeps the state in compliance
• Benefits constituents who might not have healthcare otherwise

How HMS has built the industry standard with regard to coordination of benefits:

• Feed eligibility data to established database
• Identify beneficiaries with third party coverage (10%-13% of Medicaid enrollees also have private coverage)
• Ensure that Medicaid is the ‘payer of last resort’

How to leverage advanced analytics:

• Employ visual and geospatial analysis to identify fraud
• Track members with chronic conditions (23% of members incur 90% of the costs)

HMS policy recommendations to Congress and States:

• Use third parties to ensure Medicaid is ‘payer of last resort’
• Incentivize states to improve oversight
• Leverage premium assistance programs
• Expand the use of data aggregation
• Simplify the system to reduce errors

Connect with Bill Lucia and HMS

HMS Website

Facebook

Twitter

Resources Mentioned

HMS Report: Effective Cost Management for Medicaid

Connect with Kip Piper, Host of MediStrategy

Website

Twitter

Piper Report Blog

LinkedIn

About MediStrategy:

The MediStrategy podcast offers informative interviews with healthcare leaders and insights on hot business and policy issues in Medicare, Medicaid, and health reform.  Health executives, policymakers, entrepreneurs, authors, and other influencers share challenges and opportunities in America’s rapidly changing $3.2 trillion health care system.

MediStrategy is hosted by Kip Piper, a top expert on Medicaid, Medicare, and health reform. A prominent consultant, speaker, and author, Kip Piper advises health plans, state Medicaid agencies, hospitals and health systems, provider associations, life sciences companies, and investment firms. 

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