Health Integrity, LLC
Keeping the Trust
Health Integrity is a leader in identifying and investigating potential medical fraud, waste, and abuse. Health Integrity’s mission is to protect the fiscal and clinical integrity of healthcare systems. Created in 2006, Health Integrity monitors the Medicare Prescription Drug program and investigates reports of potential fraud, waste, or abuse from Medicare beneficiaries.
Along with referring confirmed cases to the Office of Inspector General (OIG) for prosecution, Health Integrity also provides data; medical and pharmaceutical experience; audits; and training expertise. As the first Medicare Drug Integrity Contractor (MEDIC) for CMS, Health Integrity is one of only eight organizations in the country selected to monitor the Prescription Drug plan.
Health Integrity’s business includes:
Audit Medicaid Integrity Contractor (Audit MIC)
The Centers for Medicare & Medicaid Services (CMS) created the Audit Medicaid Integrity Contractor (Audit MIC) to identify Medicaid overpayments. Our primary mission is to conduct audits of Medicaid claims assigned to us by CMS across all settings of care, service types, and provider types. Health Integrity is tasked to identify as many improper payments as possible for the audits. Our team of auditors, medical claims reviewers, and data analysts review and analyze claims submitted to identify aberrant claims and potential billing vulnerabilities. The single goal is to deliver data that is “bullet-proof,”and provide findings and quality audit reports in a timely fashion. Currently Health Integrity performs MIC activities in 34 states and the District of Columbia.
Health Integrity has developed a predictive modeling tool to assist government and private organizations to identify potential cases of fraudulent medical billing. Based on our time-proven algorithms, the predictive modeling tool has well over 90% accuracy rate. Our recent successes with the tool:
- Deployed the predictive models in the Fraud Prevention System (FPS) in December, 2011 resulting in timely investigations and positive feedback from the Zone Program Integrity Contractors (ZPICs) and Program Safeguard Contractors (PSCs).
- Demonstrated predictive model accuracy with a hit rate as high as 96% (within the top 25 providers, 24 of them are tested to be fraudulent).
- Cited by CMS during a review for excellence in innovative thinking, responsiveness, and the dedication of the modeling contract staff. CMS also noted the quality and effectiveness of the predictive models as well as the team’s successful coordination with Northrop Grumman.
We are developing a secured social media environment for states and MCOs to sharing vulnerabilities. Health Integrity will provide the information technology environment, business intelligence, predictive modeling, and data analytics that mine the exchanged information.
Zone Program Integrity Contractor (ZPIC)
The ZPIC design has all lines of business which allow for very complex and comprehensive data and link analysis to be conducted on the Medicare data. This results in cases which are much greater in value and give the “whole picture” of how a beneficiary can be and is billed in Medicare.
The ZPIC also has the Medi-Medi program which looks at both Medicare and Medicaid data for the states of Texas, Colorado, and Oklahoma. The goal of this program is to analyze the data for all lines of business in Medicare and the relationships with the state Medicaid billing. The Zone 4 Medi-Medi program is responsible for more than 50% of the total savings and cases referred to law enforcement for the country. This program includes approximately 20 states across the country including states such as Florida, New York, and California.
National Benefit Integrity
Medicare Drug Integrity Contractor (NBI MEDIC)
The National Benefit Integrity Medicare Drug Integrity Contractor (NBI MEDIC) is the Medicare Part C and Part D program integrity contractor for CMS. Medicare Part C is known as Medicare Advantage and Medicare Part D is known as Prescription Drug Coverage. The purpose of the NBI MEDIC is to detect and prevent fraud, waste, and abuse (FWA) in the Part C and Part D programs on a national level. When CMS first implemented the program in 2005, Health Integrity provided coverage for the entire United States, and after December 2006, become the Southeast MEDIC covering seven states—Virginia, North Carolina, South Carolina, Tennessee, Alabama, Georgia, Florida—and Puerto Rico.
The NBI MEDIC has collaborated with CMS to define over 260 performance metrics that are reported monthly to demonstrate the NBI MEDIC’s workload, value, and return on investment (ROI). Among our recent accomplishments are:
- Handled over 7,600 calls to our Fraud Hotline that resulted in over 4,000 complaints and over 1,600 investigations
- Handled over 350 Requests for Information (RFIs) from law enforcement
- Referred over 450 cases to law enforcement
- 23 Arrests, 22 Indictments, and 14 Convictions
- Potential dollar impact of referrals—$796.5 million