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Program Integrity: Fraud & Abuse

Explore Centene Corporation's program integrity initiatives and their preventive approach to combat fraud and abuse in the healthcare industry. Learn about Centelligence™, provider partnerships, health information technology, and more.

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Program Integrity: Fraud & Abuse

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  1. Program Integrity: Fraud & Abuse Glendon Schuster Senior Vice President and Chief Technology Officer Alliance for Health Reform Panel Briefing March 5, 2012

  2. “It is the policy of Centene Corporation to conduct its business affairs in accordance with the standards and rules of ethical business conduct and to abide by all applicable laws, both in letter and spirit. In this, there is no compromise.” - Michael F. Neidorff Chairman, President and CEO

  3. Program Integrity at Centene • Conventional Methods • Preventive Approach Supporting Program Integrity

  4. Program Integrity – Conventional Methods Centelligence™ Through Centelligence™ we take our conventional methods of Program Integrity to the next level. 4

  5. Centene Preventive Approach Health Information Technology Provider Partnerships Demand for faster, more accurate payment provides opportunities for engagement. Collaboration with our State Partners Coordinated Care

  6. Centene Preventive Approach • Health Information Technology (HIT) • Administrative Efficiency / Electronic Data Interchange (EDI) • Electronic Health Records, Member Health Records, Personal Health Records, Health Information Exchange • Provider Partnerships • Provider Support – Electronic Claim Submission • Joint Venture Partnerships • Care Coordination • Member Connections • Co-Location Provider Offices and FQHC • Case Management • State Partnerships • Participate with other MCOs and State If you can run the company a bit more collaboratively, you get a better result, because you have more bandwidth and checking and balancing going on. Larry Page, co-founder of Google

  7. We identified an Ophthalmologist consistently billing procedures on five consecutive days to enrollees that lived in the same apartment complex. Review of the records indicated significant concern and the case was referred to the MFCU. EMPLOYEE EDUCATION An employee reported concerns that a home health agency may have been billing for services that the Foster Parent was providing to their Foster Child. A record review validated the allegation and identified a potential overpayment of $1.3 million. The provider was reported to OIG for potential fraud. Program Integrity - Results • Centelligence™ • Stopping Shopping • for Narcotics • System edits decreased trends in doctor shopping trends • for this group of patients at 6 months: • 95% decrease in South Carolina • 80% decrease in Ohio • 90% decrease in Florida • 98% decrease in Georgia

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