Friday, August 16, 2013

Family Docs Ask Feds to Extend Stage 2 of Meaningful Use by a Year

The American Academy of Family Physicians is asking the federal government to start Stage 2 of the electronic health records program on time, but to extend the compliance timeframe by a year.
The association, in a letter to CMS Administrator Marilyn Tavenner and ONC leader Farzad Mostashari, M.D., is concerned that regulatory expectations of Stage 2 and its existing timeframe will outstrip the capacity of many EHR vendors and ambulatory family practices to comply. “Though we do not wish to impede the progress of early adopter physicians poised for MU Stage 2 on January 1, 2014, we do not wish to see other family physicians who have committed to health care transformation through the thoughtful application of health I.T. to abandon the MU journey due to factors beyond their control.”
AAFP’s letter explains how extending Stage 2 compliance by a year would set up three distinct cohorts of physicians complying with meaningful use in different ways:
“Cohort 1 would include those eligible professionals attesting to MU in 2014 as their first payment year. They would be expected to implement 2014 CEHRT (certified electronic health record technology) and complete a reporting period of one quarter under MU Stage 1 prior to January 1, 2015, to receive their 2014 payment. In 2015, these EPs would be expected to complete an additional two quarters of MU Stage 1 prior to January 1, 2016 to receive their 2015 payment.”
“Cohort 2 would include those EPs attesting to MU in 2014 as their second payment year. They would be expected to upgrade from 2011 CEHRT to 2014 CEHRT and complete a reporting period of one quarter under MU Stage 1 criteria prior to January 1, 2015, to receive their 2014 payment. In 2015, these EPs would be expected to advance to compliance with MU Stage 2 criteria and complete a one-quarter reporting period prior to January 1, 2016, to receive their 2015 payment.”
“Cohort 3 would include those eligible professionals attesting to MU in 2014 as their third or fourth payment year. They would be expected to upgrade from 2011 CEHRT to 2014 CEHRT, advance to compliance with MU Stage 2 criteria, and complete a reporting period of one quarter prior to January 1, 2016, to receive their 2014 payment. By completing any two quarters under MU Stage 2 criteria prior to January 1, 2016, they would receive both their 2014 and 2015 payments.”

The complete AAFP letter, including a graph visually demonstrating the three-prong proposal, is available here.

Texas Uses Data Visualization to Combat Medicaid Fraud

by    |   August 15, 2013 5:43 pm   |   0 Comments
LYNXeon Medicaid data visualizaiton illustration 650x630 Texas Uses Data Visualization to Combat Medicaid Fraud
The Texas Office of Inspector General used the LYNXeon visualization tool to track connections among government payments, health care providers and Medicaid recipients. Image above is an illustration, courtesy of 21CT.
Pinning down how much taxpayer money is lost to Medicaid fraud is difficult simply because the successful frauds go undetected. But the U.S. Government Accountability Office estimated that $32.7 billion (or 10 percent) of state Medicaid payments made in 2007 were improper. Other estimates are much higher.
It’s no wonder why. A huge federal program such as Medicaid — which provides health and medical services funding to poor individuals and families — involves a byzantine network of care providers, medical institutions, pharmacies, drug manufacturers and patients spread across 50 states.
Consequently, there are a number of schemes used by providers and patients to defraud Medicaid. Among them are:
  • Billing for services not rendered
  • Double billing
  • Billing for more hours than there are in a day
  • Substituting generic drugs
  • Billing for more expensive procedures than performed
  • Kickbacks to nursing homes
  • Personal expenses in nursing home Medicaid claims

“People who are committing fraud spend all day, every day thinking about it. They come up with new ideas, they come up with ideas about how to hide their tracks. That’s their job, it’s what they do,” says Jack Stick, deputy inspector general for enforcement for the State of Texas’s Office of the Inspector General (OIG). “But people whose job it is to fight fraud do it during a regular work day. So we’ve got to think faster than they do, think better than they do, and leverage technology.”
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The technology the Texas OIG has chosen to leverage in its battle against Medicaid fraudsters is LYNXeon, a data analysis and visualization software platform designed to collect, analyze and visualize data for investigative analytics and pattern detection.
LYNXeon is made by 21CT, an Austin, Texas-based company that began in 1999 as an incubator for the U.S. Department of Defense and intelligence communities. Customers of 21CT include the branches of the U.S. armed forces, the Department of Homeland Security, and several Fortune 1000 companies.
Stick says the Texas OIG, which currently has 90 investigators tracking down Medicaid fraud in a state with more than 26 million residents and one of the highest poverty rates in the country, began loading its billions of lines of data into LYNXeon last January.
“By March we were ready to go live with 10 percent or 11 percent of the total available data,” Stick says. “They identified $20 million in potential overpayments based on just that limited amount of data.”
Once LYNXeon flags possible Medicaid fraud, Texas OIG “goes in and lays hands on the cases to do the actual investigation,” Stick says.
The power of LYNXeon, which was launched in 2004, resides in its ability to turn huge amounts of data into visualizations that allow users to see patterns they otherwise may have overlooked. For an understaffed agency charged with enforcing compliance with a massive federal program, data visualization is an invaluable tool.
LYNXeon runs data through four stages, according to Kyle Flaherty vice president of marketing for 21CT.
“It starts with machine learning models and algorithm scoring,” he says. “This spits out a bunch of leads for investigators.”
From there LYNXeon filters data through targeted queries designed to get information about specific behaviors, such as unusual billing patterns or purchases.
Stages three and four involve visualizations, he says.
“We use link analysis to determine context between people, places and things,” Flaherty says. “By visualizing the connection paths, LYNXeon allows investigators to expand and pivot off this information and get to the root of how they’re perpetrating fraud.”
Finally, pattern and social networking analytics “can really arm a good investigator to find something he never could before,” he says.
Stick says this is especially true when you use a wide range of data.
“What we’re doing with LYNXeon is adding in Medicaid data, Medicare data, Dun & Bradstreet data,” he says. “So if we find that a provider bills for a lot of procedures, but Dun & Bradstreet  tells us that they never turn the electricity on, that’s a pretty good indicator that there’s waste, fraud and abuse going on.
“We also can look at the Medicaid payment data and put it into context,” Stick says. “We can compare that provider to his or her peers, we can look to see if they’re in a building that’s physically large enough to house what they’re doing.”
LYNXeon also gives Texas OIG the ability to investigate recipients of Medicaid and other benefit programs.
“We can see if your EBT (Electronic Benefit Transfer) card is active in Dallas one day, but you’re receiving Medicaid services in Houston on the same day,” Stick says. “And we can track retailers that are fraudulently buying electronic benefits for pennies on the dollar and then redeeming them for full value.”
Nearly six months since going live, Stick says LYNXeon has identified more than $180 million in potential Medicaid overpayments for Texas OIG to investigate.
“If only a fraction of what we’ve identified through LYNXeon proves to be waste, fraud and abuse, and we recover that money or at least avoid spending that money in the future, we will already have paid for LYNXeon,” says Stick. “It’s by far the best money I have ever spent in government.”
Contributing Editor Christopher Nerney ( is a freelance writer in upstate New York. Follow him on Twitter: @ChrisNerney.
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