Clinical Integrity

Ensuring appropriate, cost-effective care

Community Care network staff has long used claims data to identify patients who may be in need of more help or care management. In perusing claims, an occasional irregularity appears -- home services billed on a day a patient was an inpatient, a double charge for a service only provided once, etc. In CCNC’s role of promoting appropriate, cost-effective, and evidence-based care, we forged a relationship with the Division of Medical Assistance Program Integrity section and together formed a “Clinical Integrity team.” The CI team consists of physicians, data analysts, and select members of the Special Projects unit at the DMA Program Integrity section. This group has been meeting regularly since November of 2010 to discuss and initiate investigation of aberrant claims.

As part of this effort, the Division of Medical Assistance runs “outlier reports” run each quarter. This report picks up claims that stand out -- for example when claims show units billed for a procedure that are several standard deviations higher than the mean number of units billed for that procedure code for the year. Physicians review these reports and remove entries that are explainable by reference to Medicaid claims data. 

CCNC care managers have become an important source of information for the CI team, reporting cases where providers appear to be billing for goods and services not supplied the patient, for instance. Further investigation ensues only if an initial clinical review by the CI team finds cause to continue. If criminal activity is apparent (pattern of billing for patients after their death, for instance), the investigation is passed on to the appropriate authorities. If Clinical Policy issues are found, the CI team meets with the appropriate DMA Clinical Policy staff to discuss them. 

The Clinical Integrity team is committed to ensuring that Medicaid beneficiaries get appropriate, cost-effective, and evidence-based care.