Medicaid Program Integrity Data Analytics and Case Tracking System

Agency: State Government of New Hampshire
State: New Hampshire
Level of Government: State & Local
Category:
  • 65 - Medical, Dental, and Veterinary Equipment and Supplies
  • 70 - General Purpose Information Technology Equipment (including software).
  • A - Research and development
  • D - Automatic Data Processing and Telecommunication Services
  • R - Professional, Administrative and Management Support Services
Opps ID: NBD14608486439324035
Posted Date: Dec 30, 2020
Due Date: Feb 10, 2021
Solicitation No: RFI-2021-OCOM-01-MEDIC
Source: Members Only
Description This Request for Information (RFI) is published to solicit information regarding data analytics services and products that analyze Medicaid claims data and assist in the detection of fraud, waste, and abuse.
Documents RFI-2021-OCOM-01-MEDIC
Release Date December 30, 2020
Closing Date/Time February 10, 2021
Program Area Office of the Commissioner, Program Planning and Integrity
Contact Jennifer Hackett
Telephone (603) 271-9605
E-mail Address Jennifer.Hackett@dhhs.nh.gov

Attachment Preview

State of New Hampshire
Department of Health and Human Services
REQUEST FOR INFORMATION #RFI-2021-OCOM-01-MEDIC
FOR
Medicaid Program Integrity Data Analytics and Case Tracking
System
December 30, 2020
New Hampshire Department of Health and Human Services
Medicaid Program Integrity Data Analytics and Case Tracking System
REQUEST FOR INFORMATION
1. Overview and Purpose
1.1. Overview
This Request for Information (RFI) is published to solicit information regarding data
analytics services and products that analyze Medicaid claims data and assist in the
detection of fraud, waste, and abuse.
1.2. Purpose
The Department is in need of a data analytics system that can analyze claims data
from the Medicaid system in order to identify possible trends, as well as specific
instances of provider fraud, waste, and abuse. Additionally, the Department is seeking
a case tracking system with the ability to effectively manage fraud, waste, and abuse
case referrals and case status.
2. Background Information
2.1. Medicaid program integrity is required in accordance with 42 CFR Part 455,
which mandates that Medicaid agencies have methods and criteria for
identifying suspected fraud, as well as methods for investigating these cases
that:
2.1.1. Do not infringe on the legal rights of persons involved;
2.1.2. Afford due process of law; and
2.1.3. Refer suspected fraud cases to law enforcement officials using
procedures developed in cooperation with State legal authorities.
2.2. The Department of Health and Human Services, Bureau of Improvement and
Integrity, Program Integrity Unit is tasked with detecting fraud, waste, and
abuse of the providers in the Medicaid program. The Unit must then recover
these funds or refer the provider for prosecution, if the provider’s behavior
rises to the level of fraud.
2.3. In New Hampshire, the number of clients enrolled in Medicaid is approximately
187,000, of which:
2.3.1. Approximately 131,000 clients are enrolled in standard Medicaid. Of
those enrolled, approximately 15,000 are Children’s Health Insurance
Program (CHIP) clients.
2.3.2. Approximately 56,000 clients are in the expansion population.
2.4. There are approximately 30,600 Medicaid providers enrolled in NH Medicaid.
New Hampshire Medicaid services are provided by three (3) Managed Care
organizations, with a limited number of services covered by the State Medicaid
agency through a Fee-for-Service structure. In State Fiscal Year 2019,
approximately $654,159,957 in claims were processed by the Managed Care
organizations, and approximately $773,372,083 were processed by the State
Medicaid agency for Fee-for-Service.
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RFI-2021-OCOM-01-MEDIC
New Hampshire Department of Health and Human Services
Medicaid Program Integrity Data Analytics and Case Tracking System
2.4.1. There are a number of services covered through the Managed Care
companies, which include but are not limited to:
2.4.1.1. In-patient hospital care and rehabilitation services.
2.4.1.2. Physician services.
2.4.1.3. Prescription drug services.
2.4.1.4. Physical therapy.
2.4.1.5. Skilled nursing Home Health Aide assisted physical therapy.
2.4.1.6. Occupational therapy.
2.4.1.7. Speech therapy.
2.4.1.8. Private duty nursing care.
2.4.1.9. Emergent and non-emergent medical transportation.
2.4.1.10. Durable medical equipment.
2.4.1.11. Psychotherapy.
2.4.1.12. Podiatry Advanced Practice Registered Nurse (APRN)
services.
2.4.1.13. Midwife services.
2.4.1.14. Early and Periodic Screening, Diagnostic, and Treatment
(EPSDT).
2.4.1.15. Laboratory and radiology services.
2.4.1.16. Hospice care.
2.4.2. Additionally, there are carve-out services covered under the Fee-for-
Service structure, which include but are not limited to:
2.4.2.1. Medicaid to School medical services.
2.4.2.2. Pediatric dentistry services.
2.4.2.3. Home and Community-based care for the elderly.
2.4.2.4. Home and Community-based care for developmental services.
2.4.2.5. Acquired brain disorders.
2.4.2.6. Children with special needs or disability waivers.
2.4.2.7. Long-term nursing facility care.
2.4.3.
Of the total number of clients enrolled for services, approximately 185,000
are enrolled in one of the three Managed Care agencies, and
approximately 2,000 receive all Medicaid services through the Fee-for-
Service system.
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RFI-2021-OCOM-01-MEDIC
New Hampshire Department of Health and Human Services
Medicaid Program Integrity Data Analytics and Case Tracking System
3. Objectives
3.1. Preliminary Objectives
3.1.1. The Department’s preliminary objectives are data analytics that will
reduce Medicaid provider fraud, waste and abuse and a case
management system to manage the caseload, including:
3.1.1.1. Developing a data analytics system that will analyze
Medicaid claims data to assist in the detection of fraud,
waste and abuse. Identify best practices and available
technology in the area of data analytics as it could aid in
identifying Medicaid Provider fraud, waste, and abuse.
3.1.1.2. Developing a case management system to manage the
caseload. This should include, but not be limited to,
communications, assignments, documentation status, and
results of a referral once it is identified as a possible referral and
possibly proceeds to an investigation and/or prosecution.
3.2. RFI Objectives
3.2.1. Primary Objectives
3.2.1.1. The primary objectives of this RFI are to solicit information
regarding data analytics services and products, as well as
information regarding a case tracking system, to identify
possible approaches, solutions and systems that may assist the
Department’s Medicaid program integrity units in the
elimination, investigation, and/or prosecution of fraud, waste,
and abuse.
3.2.2. Data Analytics
3.2.2.1. The Department envisions a Data Analytics System which will
assist in the primary objectives as stated in Section 3.2.1.
3.2.2.2. The Department requires the Data Analytics System be secure,
and the Vendor’s security profile for the data structure allow for
either an on premise solution or “Software as a Service”.
Additionally, it is desired that the System meet the security and
compliance standards such as Health Information Trust Alliance
(HITRUST) or Minimal Acceptable Risk Standards for
Exchanges (MARS-E).
3.2.2.3. The Data Analytics System must be a secure environment with
data hosting capabilities, such as on-site, hosted, web portal,
Oracle, or cloud-based.
3.2.2.4. The Data Analytics System must employ methods such as
algorithms, data analytics, and/or utilization analysis in fraud
and abuse detection. The Department desires algorithms
helpful in the detection of flags in Managed Care Organization
data.
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RFI-2021-OCOM-01-MEDIC
New Hampshire Department of Health and Human Services
Medicaid Program Integrity Data Analytics and Case Tracking System
3.2.2.5. The Data Analytics System must be capable of running
algorithms, building and executing statistical models using
Medicaid data, and building models for analyzing data that
include identifying a population and assessing whether a
service was provided.
3.2.2.6. The Data Analytics System must be capable of integrating
different types of data such as provider, member, claims, and
encounter data.
3.2.2.7. The Department expects that analytics will be conducted using,
at a minimum, Managed Care Contractor (MCC) encounter
data, which is maintained by the Department.
3.2.2.8. The Department envisions a Data Analytics System with
customizable interfaces, configurable to the Department’s
current data elements, and capable of being updated to meet
the demands of System users.
3.2.2.9. The Data Analytics System should utilize industry standard
approaches or scripts for data extraction that are capable of
being customized in order to be applied to the Department’s
systems.
3.2.2.10. The Data Analytics System must be configurable or capable of
using a common identifier to tie data together and detect
patterns at the larger system level, as well as the individual
provider level. For example, if one system identifies a provider
by National Provider Identifier Standard (NPI), and another
system identifies the provider by provider ID, the system should
be capable of tying these identifiers together to identify certain
patterns.
3.2.2.11. The Data Analytics System should offer reference tables for
standard code sets, such as National Drug Codes (NDC),
procedure and diagnostic codes, and have a structure capable
of interacting with end reporting. The Department desires that
the tables and table storage be well organized and potentially,
also customizable.
3.2.2.12. The Data Analytics System should include a process for
integrating historical case information from existing databases,
known as a look-back capability, with the ability to specify
certain time periods.
3.2.2.13. The Data Analytics System should include reports that identify
key performance indicators around recovery and return on
investment.
3.2.2.14. The Data Analytics System must have reporting and dashboard
capabilities which promote the identification of leads in fraud
and abuse risks and ease of use.
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RFI-2021-OCOM-01-MEDIC
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