May 12, 2010, MONTGOMERY, Ala. & EDEN PRAIRIE, Minn.--The State of Alabama Medicaid Agency has strengthened its commitment to payment accuracy and taxpayer value by awarding a two-year, performance-based contract to Ingenix to review claims and identify any funds owed to the state.
The agency, recognized nationally for its payment and eligibility accuracy, will work with Ingenix on a focused post-payment review of claims filed for the past two years by all Alabama-based healthcare provider groups, including hospitals, physicians, dentists, pharmacies, durable medical equipment companies, and home health care providers.
Under terms of the agreement, rather than receiving a flat contract fee, Ingenix will be paid a percentage of any incorrect payments identified and recovered.
Ingenix will provide the agency with fraud, waste, abuse, and overpayment identification and collection tools and services, such as data mining, analytics, and detection algorithms. These include "Alabama specific" algorithms and models tailored to payment rules and priorities determined by the state. Ingenix will also provide the Alabama Medicaid Agency with experts experienced in Medicaid policies and procedures, claims processing, reimbursement policy analysis, and provider relations.
"The goal of this agency is to make sure every public dollar is properly spent to improve the health of the people of Alabama, and to achieve that, we need to continuously seek ways to strengthen our program integrity and fraud-and-abuse prevention efforts," said Alabama Medicaid Commissioner Carol Steckel, who also serves as chairperson of the National Association of State Medicaid Directors (NASMD). "A contingency-based contract ensures that Alabama taxpayers are only paying for results."
The agreement will bolster Alabama Medicaid's comprehensive Program Integrity initiative, which already includes the following components, separate from this agreement:
- a review of the list of sanctioned individuals to ensure that they are not working in any capacity for an entity that receives payments from Medicaid or Medicare
- a more rigorous review of any provider enrollment application in which the applicant has previously been sanctioned or suspended
- a requirement that Medicaid beneficiaries who have their eligibility reinstated after being suspended from the Medicaid program for drug-related fraud, abuse, or misuse of benefits be placed in the restriction program and have their utilization of benefits monitored for one year
- a review of new applications of durable medical equipment providers prior to enrollment to ensure they have a legitimate office and office staff
In fiscal year 2009, Alabama Medicaid reviewed 77 medical providers and 413 pharmacies, resulting in approximately $1.3 million in recoveries and nearly $4 million in cost avoidance. More than 100 beneficiaries were suspended from Medicaid for abuse or misuse of the program and nearly 700 were restricted or "locked in" to one doctor and one drug store to prevent potential abuse. Alabama's quality-control rate, which measures the accuracy of the agency's eligibility determination process, consistently out-performs the national average of three percent. The agency's most recent error rate was only one-half of one percent for the year.
"The Alabama Medicaid Agency has made payment accuracy a priority, and we are proud to work with the state in its innovative efforts to ensure that taxpayer dollars are spent properly and cost effectively to support the health of the people of Alabama," said Shelby Solomon, executive vice president, commercial and government health plan solutions at Ingenix.
Ingenix provides payment accuracy solutions and services for several state Medicaid agencies across the country.
About Alabama Medicaid Agency
The Alabama Medicaid Agency manages and administers the state's Medicaid program in order to fund medical and long-term care services for low-income pregnant women, children, certain people on Medicare, disabled individuals and nursing home residents. Assisting nearly 1 million eligible recipients annually, or about 20 percent of Alabama's population, the Agency is actively involved in health information technology development and quality improvement initiatives in order to improve patient health outcomes, to control and reduce costs, and simplify the way Medicaid does business. www.medicaid.alabama.gov
Ingenix, a wholly owned subsidiary of UnitedHealth Group (NYSE:UNH), transforms organizations and improves health care through information and technology. Organizations rely on its innovative products, services and consulting to improve the delivery and operations of their business. More information about Ingenix can be obtained at www.ingenix.com.