Program Integrity Unit

$ Amount Cost Avoidance Generated by the Program Integrity Unit

$724,263SFQ1 2021

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Notes on Methodology
  • Please note while there is no specific target for this measure, the goal is to increase avoidance amount over time by increasing the number of providers we are in contact with and the removal of beneficiaries that are no longer eligible for benefits.

Partners
  • Policy Unit
  • Clinical Operations Unit
  • Provider Member Relations Unit
  • Agency of Human Services Central Office
  • Medicaid Providers
  • DXC
  • OneCare Vermont
Story Behind the Curve

One of the Program Integrity’s Unit (PIU) approaches to prevent fraud, waste and abuse of Medicaid funds, is to avoid the cost entirely through cost-avoidance.  In essence, when you cost-avoid unnecessary or inappropriate funds from being paid out, the program is preventing waste and abuse.   The performance data compiled to date indicates the more providers PIU comes in contact with, the more cost avoidance is realized.  Therefore, one goal of the PIU is to interact with as many providers as possible. PIU seeks to measure the effectiveness of PIU involvement in proactive audits and cases to determine if the provider changed their billing patterns going forward after PI involvement.  The actual recovery of funds paid out due to fraud, waste, or abuse is an important function of PIU, but to prevent the funds from being paid initially prevents the loss of funds.

PIU measures the change in a provider’s activity commencing on the day the provider was contacted by PIU.  The date of contact could be a request for records, site visit, interview, etc.  For example, a provider changing their billing pattern from a higher reimbursed procedure code to the more accurate lower amount reimbursed code is calculated from the date the provider is contacted by PIU to the present date.  The difference in reimbursement between the two codes from the contact date to present date is quantified and complied. 

PIU also records cost avoidance when we are involved in the removal of beneficiaries from Vermont Medicaid that are no longer eligible for benefits.  Removal of beneficiaries from Vermont Medicaid is important if the member is attributed to the ACO, as DVHA pays the ACO a PMPM fee for each member attributed. 

The chart depicts the quarterly impact of our cost avoidance measured to date for both our provider and beneficiary cost avoidance. 

Last updated:  10/15/2020

Strategy

The goal of the PIU is to continue to increase the quarterly cost avoidance amount over time by increasing the number of providers we are in contact with and the removal of beneficiaries that are no longer eligible for benefits.  PIU seeks to interact with providers through proactive provider audits, educational outreach opportunities, and through case referrals.  PIU strives to educate providers as appropriate, recover funds when necessary, and successfully prevent and cost-avoid Medicaid funds. 

Scorecard Result Container Indicator Measure Action Actual Value Target Value Tag S R I P PM A m/d/yy m/d/yyyy