The Centers for Medicare & Medicaid Services (CMS) awarded AdvanceMed Corporation an Umbrella Medicaid Integrity Contract (MIC) in December 2007 and the Region 6 Task Order (TO) was awarded in September 2008. The MIC team conducts data mining analysis and performs risk assessment of Medicaid data of claims for payment under the State Plan of Title XIX or any approved waiver of such plan for the Region 6 states: Arkansas, Louisiana, Oklahoma, Texas, and New Mexico. The analysis is conducted to determine whether fraud, waste, or abuse has occurred, or is likely to occur; and to determine if such actions have any potential for resulting in an expenditure of funds.

The MIC team performs the following functions for CMS as a Review MIC:

• Develops models, runs, and edits algorithms as directed by the CMS Division of Fraud Research and Detection (DFRD);
• Utilizes the CMS Medicaid Statistical Information System (MSIS) database and the Medicaid Integrity Group (MIG) Data Engine to perform data mining and risk assessments;
• Provides clinical input for defining coding, state practice acts; and communicating with Medicaid staff in the states to determine standards of care in a particular community or region;
• Provides recommended leads to CMS’s Division of Fraud Research and Detection (DFRD) for approval and referral to the Audit and Identification of Overpayment Medicaid Integrity Contractor (Audit MIC) for those individuals or entities identified as receiving overpayment of federal Medicaid funds;

The AdvanceMed approach is to invest time and effort in validating the data analytics, processes, and results by proactively limiting the number of false positives; increasing the success of audit leads; increasing customer satisfaction by delivering actionable leads; and maximizing Return on Investment (ROI).

Client:
Centers for Medicare & Medicaid Services (CMS)

Location:
Nashville, Tennessee

Program Manager:
Tom Mathis
mathist@admedcorp.com