2010 Idea Factory Pilot
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Clean up and Standardize Medicaid and CHIP data. Create CM Master Beneficiary and Provider Profiles
Create CMS Enterprise Beneficiary and Provider Profiles to include CHIP, Medicaid, and Medicare data
9 votesOIS responded that your idea is currently in the planning and early development phases. The vision of the Master Data Management (MDM) system is to use modern data engineering methods and tools to provide complete profiles of Medicare, Medicaid and Children’s Health Insurance Program data. The MDM system will offer a suite of services that will allow CMS to link and synchronize Beneficiary, Provider, and Organization data from multiple disparate sources.
Provider and Beneficiary profiles, or Books of Records, will be obtainable through a single call to a trusted, authoritative data service that is part of the MDM system. Additional cost estimates to include Medicaid/CHIP data into the MDM has been estimated to be $60Million dollars over several years.
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CMS should pursue all overpayments regardless of the amount.
Too often CMS upper mgmt says that 1 million or 5 million dollar overpayments are too small to pursue. If CMS would make an effort to recover all overpayments, perhaps providers would be more cautious in submitting claims.
5 votesCMS agrees that all overpayments must be pursued. CMS collects all overpayments that have been calculated, that are greater than $100.
The commenter may have been referring to the development of cases that are believed to be small dollar value prior to the calculation of the overpayment. Resource constraints have historically been the driver of that approach. CMS, its contractors and law enforcement have prioritized their case load to go after high dollar value cases or instances where patient safety may be compromised.
CPI believes the new approaches to fraud detection being implemented through predictive analytics, as well as streamlining existing processes, will permit us to be able to take more actions in a shorter amount of time with the same amount of resources.
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Tighten standards for successful claims appeals.
CMS’s efforts to obtain billing compliance from doctors and to establish more uniform application of Medicare policies are hindered by idiosyncratic appeal decisions, particularly at the Administrative Law Judge level. Not infrequently, the appeals decisions are made in favor of granting payments that at odds with both expressed and intended Medicare policy. A result of those decisions is that precedents may be established to make those policies unenforceable. Furthermore, a loose application of policy and lack of deference to a reasonable decision made by medical reviewers or lower level appeal venue encourages providers that bill aggressively to maximize revenue by…
6 votesCPI agrees that there is an area of vulnerability if the appeals standards appear to be inconsistent or frequently overturned. CPI is in the process of setting up a workgroup to address these concerns.
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CMS would focus more on evidence based decision making
CMS routinely conducts audits of Medicare Advantage plans. However, CMS would focus more on the audit findings to make policy decisions. In terms of claims fraud, CMS would ensure staff are competent in this area. Everyone that conducts audits may not know what a CPT code is and how it relates to the claim. Additionally, CMS would consider finding and appraising evidence from the audits and investigations and use the information to impact policy.
6 votesOFM is currently developing a comprehensive vulnerability tracking system with input from CPI. The system will capture significant issues from a variety of contractors to identify program vulnerabilities, including contractors that oversee the Medicare Advantage plans. CMS will then implement corrective action plans, which could include policy and/or operational improvements, to address the vulnerability.
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Compile fraud profiles based on data pulled from CMS/IRS/state Medicaid etc. and use to ID new fraud
Pull data from across platforms, including 1-800-Medicare, mymedicare.gov, IRS data, state Medicaid and other claims. Create profiles from known fraud cases and use new data to inform and pursue potential cases of fraud.
18 votesCPI is working to develop just these types of fraud profiles both for individuals and for the identification of new schemes. The National Fraud Prevention Program is designed to incorporate lessons learned on an on-going basis through a continual feedback loop in the analytics.
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Give CMS employees instant messaging to save time and resources
Implement an internal instant messaging system throughout CMS. By utilizing this technology a lot of time and resources could be saved that is otherwise taken up walking to peoples cubes, unnecessarily using e-mail server space for quick questions.
88 votes -
12 votes
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13 votes
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Have classes from the Federal Acquisition Institute on site at CMS.
There are a variety of classes offered through the Federal Acquisition Institute (FAI). CMS could explore having FAI bring some of those course offerings on site at CMS and negotiate an Inter-Agency Agreement with FAI.
15 votes -
Redesign training that is more case-study based of the top 5 types of contracts a PO will encounter.
Redesign training that is more case-study based of the top 5 types of contracts a PO will encounter.
19 votes -
Clearly define the roles for the COTR and the GTL and train them each accordingly
Clearly define the roles and responsibilities for both the COTR and the GTL so that each are clear. Train the COTR's and GTL's according to the defined division of work.
19 votes -
22 votes
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27 votes
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Start a COTR - Contract Specialist issues forum to discuss CMS-relevant cases from both viewpoints.
Right now, must training is a one way conversation from OAGM to COTR's. Yet training courses have consistently been filled with questions that would be more easily resolved if contract specialistis and contracting officers were involved in the discussion. CO's & CS's can learn from COTR's in terms of improved processes AND better trained COTRs.
37 votes
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