122125 O3 Attachment 5 - CMS Certification Outcomes and Metrics.docx.pdf
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- Attached to
- Program Integrity Case Management (PICM) and Fraud Abuse Detection (FAD) Analytics Solution
- Solicitation number
- 122125 O3
- Issued by
- Blaine County, Nebraska
About this file
This document is Attachment 5 for RFP 122125 O3, a CMS (Centers for Medicare & Medicaid Services) Certification Outcomes and Metrics document for a Program Integrity Case Management System. The attachment details specific system requirements and outcomes for a Program Integrity Case Management System (PICM) with a FADS Analytics module, focusing on tracking, identifying, and managing potential fraud, abuse, and improper payments within a Medicaid program. The document outlines multiple regulatory compliance requirements derived from various C.F.R. sections and specific state requirements.
The outcomes describe critical system capabilities, including accurately tallying recoupments, tracking repayments, identifying patterns of fraud and abuse, supporting retrospective drug utilization reviews, referring suspected provider fraud cases to the state's Medicaid Fraud Unit, and generating reports to evaluate program trends and identify billing practice outliers. The system is expected to provide comprehensive analytics and case management tools for state users to report fraud, conduct ad-hoc research, and maintain program integrity. The requirements are explicitly tied to specific regulatory sources, primarily 42 C.F.R. sections, and are designed to support detailed tracking, reporting, and investigation of potential improper payments and fraudulent activities.
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Text version
Attachment 5 CMS Certification Outcome and Metrics
RFP 122125 O3
Program Integrity Case Management System
Outcome
Reference #
Outcome Description CMS Required
Regulatory
Source(s) or
State Specific
Outcome Applicability
FM5 The system accurately tallies recoupments by tracking repayments and amounts outstanding for individual transactions and in aggregate for a provider.
42 C.F.R. 447 FM5 is applicable to the PICM / FADS
Analytics Module. The PICM / FADS
Analytics module tallies recoupments by tracking repayments and amounts outstanding for individual transactions and in aggregate for a provider.
PBM9 The system supports the identification of patterns of fraud, abuse, gross overuse, or inappropriate or medically unnecessary care, or prescribing or billing practices indicating abuse or excessive utilization among physicians, pharmacists and individuals receiving benefits by enabling the collection of pharmacy data to be used in retrospective drug utilization reviews.
42 C.F.R.
456.703, 456.705(b), 456.709
Section 1927
(g) of the SSA
PBM9 is applicable to the PICM / FADS
Analytics module. The system supports the identification of patterns of fraud, abuse, gross overuse, or inappropriate or medically unnecessary care, or prescribing or billing practices indicating abuse or excessive utilization among physicians, pharmacists and individuals receiving benefits by enabling the collection of pharmacy data to be used in retrospective drug utilization reviews.
PI2 System provides a method for identifying suspected inappropriate services and incorrect billing.
42 C.F.R.
455.13
PI12 is applicable to the PICM / FADS
Analytics module. The system provides a method for identifying suspected inappropriate services and incorrect billing.
PI6 System can recover improper payments by:
(a) Tracking repayments and outstanding amounts due at an individual transaction level as well as aggregating by provider, time period
(b) Supporting electronic transfer back to the state
(c) Temporarily limiting future payments to provider(s) who have an outstanding recovery balance.
42 C.F.R. 447
42 C.F.R.
431.1002
42 C.F.R.
433.300-322
(a) Payment tracking is expected from the PICM / FADS Analytics solution
(b) Not applicable
(c) Not applicable
Attachment 5 CMS Certification Outcome and Metrics
RFP 122125 O3
Program Integrity Case Management System
PI10 System can refer all cases of suspected provider fraud to the state's Medicaid Fraud Unit and provide access to Case Tracking as applicable.
42 C.F.R.
455.21(a)
PI10 is applicable to the PICM / FADS
Analytics module. The system can refer all cases of suspected provider fraud to the state's Medicaid Fraud Unit and provide access to Case Tracking as applicable.
PM17 A state user can report required information about fraud and abuse to the appropriate officials.
42 CFR 455.17 PM17 is applicable to the PICM / FADS
Analytics module. A state user can report required information about fraud and abuse to the appropriate officials.
ST26 SMA utilizes automated case management and reports for fraud and abuse analysis and investigations.
State Specific Applicable
ST27 The system generates reports to evaluate program trends and identify outliers in Provider billing practices and Member service utilization to identify potential utilization anomalies.
State Specific Applicable
ST28 The system provides access to post payment data and flexibility to conduct ad hoc research for a case.
State Specific Applicable
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