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
Attachment 5 is a CMS Certification Outcome and Metrics document for the State of Nebraska's Department of Health and Human Services (DHHS) Program Integrity Case Management System (RFP 122125 O3). The document details specific regulatory requirements and system outcomes for a proposed Fraud Analysis & Detection (FADS) module, focusing on eight key performance metrics that align with federal regulations such as 42 C.F.R. sections 447, 455, and 456. The outcomes cover critical functions including tracking recoupments, identifying fraud and abuse patterns, detecting inappropriate services and billing, referring suspected provider fraud cases, and generating reports to evaluate program trends and provider billing practices.
The metrics are primarily applicable to the PICM/FADS Analytics module and are sourced from both federal regulatory requirements and state-specific needs. Key system capabilities include accurately tallying recoupments, supporting retrospective drug utilization reviews, identifying patterns of fraud or abuse, tracking repayments, providing methods for recovering improper payments, enabling state users to report fraud information, and generating comprehensive reports for program analysis. While specific implementation details are not fully elaborated in this attachment, the document demonstrates a structured approach to ensuring system compliance with federal Medicaid program integrity standards and state-level investigative requirements.
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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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