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For Limited DistributionThe following disclaimer applies: Regarding all Healthcare Fraud Prevention Partnership communications and activities, this is a purely voluntary activity. The committees
regarding data sharing and analysis; information sharing; and the Executive Board, are to be used solely as discussion groups where the individual members can share facts or information or individual input. No group or consensus advice or recommendations will be given by the partners in the committees or the Executive Board. In addition, no policy-making or decision-making will be performed by the committees or the Executive Board. The Secretary and the Attorney General or their designees will make the final policies or
other decisions.
HEALTHCARE FRAUD PREVENTION PARTNERSHIP(HFPP) Overview
June, 2013
For Limited Distribution
The following disclaimer applies: Regarding all Healthcare Fraud Prevention Partnership communications and activities, this is a purely voluntary activity. The committees regarding data sharing and analysis; information sharing; and the Executive Board, are to be used solely as discussion groups where the individual members can share facts or information or individual input. No group or consensus advice or recommendations will be given by the partners in the committees or the Executive Board. In addition, no policy-making or decision-making will be performed by the committees or the Executive Board. The
Secretary and the Attorney General or their designees will make the final policies or other decisions.
ENDLESS OPPORTUNITIES…..
HFPP
Claims
Compromised Patient Data
Fraudulent Providers
Par
tner
#Z
Partner #X
Partner #Y
Enhanced
Fraud-
Fighting
Capabilities
For Limited Distribution
The following disclaimer applies: Regarding all Healthcare Fraud Prevention Partnership communications and activities, this is a purely voluntary activity. The committees regarding data sharing and analysis; information sharing; and the Executive Board, are to be used solely as discussion groups where the individual members can share facts or information or individual input. No group or consensus advice or recommendations will be given by the partners in the committees or the Executive Board. In addition, no policy-making or decision-making will be performed by the committees or the Executive Board. The
Secretary and the Attorney General or their designees will make the final policies or other decisions.
PURPOSE OF THE HEALTHCARE FRAUD PREVENTION PARTNERSHIP (HFPP)
• To exchange facts and information between the public and private sectors in order to reduce the prevalence of health care fraud
• To enable members to individually share successful anti-fraud practices and effective methodologies and strategies for detecting and preventing health care fraud
• To focus on information sharing in two primary areas:• Data sharing and analytics• Outreach, education and information sharing
For Limited Distribution
The following disclaimer applies: Regarding all Healthcare Fraud Prevention Partnership communications and activities, this is a purely voluntary activity. The committees regarding data sharing and analysis; information sharing; and the Executive Board, are to be used solely as discussion groups where the individual members can share facts or information or individual input. No group or consensus advice or recommendations will be given by the partners in the committees or the Executive Board. In addition, no policy-making or decision-making will be performed by the committees or the Executive Board. The
Secretary and the Attorney General or their designees will make the final policies or other decisions.
PROGRESS TO DATE
• Officially established by a Charter in fall 2012• Signed by HHS Secretary Sibelius and US Attorney General Holder
• Members joined from Federal & State government, private payers and associations
• Created operating structures and processes• Established legal framework (e.g., MOU)• Established regular meetings and coordination• Completion of the First Information Exchange
For Limited Distribution
The following disclaimer applies: Regarding all Healthcare Fraud Prevention Partnership communications and activities, this is a purely voluntary activity. The committees regarding data sharing and analysis; information sharing; and the Executive Board, are to be used solely as discussion groups where the individual members can share facts or information or individual input. No group or consensus advice or recommendations will be given by the partners in the committees or the Executive Board. In addition, no policy-making or decision-making will be performed by the committees or the Executive Board. The
Secretary and the Attorney General or their designees will make the final policies or other decisions.
CURRENT PARTNERSHIP AS OF APRIL 1, 2013
Federal Partners• Department of Health and Human Services, Associate Deputy
Secretary’s Office• Department of Health and Human Services, Centers for
Medicare and Medicaid Services• Department of Health and Human Services, Office of the
Inspector General• Department of Justice, Criminal Division• Department of Justice, Federal Bureau of Investigations
State Partners• Arizona Medicaid Office of the Inspector General, Arizona Health
Care Cost Containment System• New York Office of Medicaid Inspector General • Iowa Insurance Fraud Bureau (NAIC’s representative on the
Information Sharing Committee) • Ohio Attorney General’s Office (NAMFCU’s representative on the
Information Sharing Committee)• Kansas Attorney General’s Office (NAMFCU’s representative on
the Executive Board)
Private Payers • Aetna• Amerigroup • Blue Cross and Blue Shield of Alabama • Blue Cross and Blue Shield of Louisiana • Humana • Independence Blue Cross • Travelers • Tufts Health Plan • United HealthCare• WellPoint
Associations• America's Health Insurance Plans (AHIP)• Blue Cross and Blue Shield Association
(BCBSA)• Coalition Against Insurance Fraud (CAIF)• National Association of Insurance
Commissioners (NAIC)• National Association of Medicaid Directors
(NAMD)• National Association of Medicaid Fraud Control
Units (NAMFCU)• National Health Care Anti-Fraud Association
(NHCAA)• National Insurance Crime Bureau (NICB)
For Limited Distribution
The following disclaimer applies: Regarding all Healthcare Fraud Prevention Partnership communications and activities, this is a purely voluntary activity. The committees regarding data sharing and analysis; information sharing; and the Executive Board, are to be used solely as discussion groups where the individual members can share facts or information or individual input. No group or consensus advice or recommendations will be given by the partners in the committees or the Executive Board. In addition, no policy-making or decision-making will be performed by the committees or the Executive Board. The
Secretary and the Attorney General or their designees will make the final policies or other decisions.
STRUCTURES OF THE HFPP
Executive Board
Information Sharing Committee (ISC)
Data Analysis & Review Committee (DARC)
Study 1 Study 2 Study 3 Study 4 Study 5
Trusted Third Party
Life CycleTeam
Study Pipeline
Team
TTP Strategy
TTP NASAChallenge
Other Teams
Fo
rmal
S
tru
ctu
res
Stu
die
sP
lan
nin
g
Team
s
For Limited Distribution
The following disclaimer applies: Regarding all Healthcare Fraud Prevention Partnership communications and activities, this is a purely voluntary activity. The committees regarding data sharing and analysis; information sharing; and the Executive Board, are to be used solely as discussion groups where the individual members can share facts or information or individual input. No group or consensus advice or recommendations will be given by the partners in the committees or the Executive Board. In addition, no policy-making or decision-making will be performed by the committees or the Executive Board. The
Secretary and the Attorney General or their designees will make the final policies or other decisions.
DATA SHARING CONCEPT
Trusted Third Party
Government Partner #1
Government Partner #2
Private Payer #....
Private Payer #2
Private Payer #1
• Study Selection
• Design & Planning
• Data Exchange• TRUSTED 3rd PARTY
• Partner Data Analysis & Actions
• Evaluation
For Limited Distribution
The following disclaimer applies: Regarding all Healthcare Fraud Prevention Partnership communications and activities, this is a purely voluntary activity. The committees regarding data sharing and analysis; information sharing; and the Executive Board, are to be used solely as discussion groups where the individual members can share facts or information or individual input. No group or consensus advice or recommendations will be given by the partners in the committees or the Executive Board. In addition, no policy-making or decision-making will be performed by the committees or the Executive Board. The
Secretary and the Attorney General or their designees will make the final policies or other decisions.
ISC – EXTENT OF INFORMATION SHARING
General Public
HFPP Partner Extensions (e.g.
association members)
HFPP Full Partnership
Participating Entities
Each individual HFPP data exchange study will be analyzed to determine:
1. What level of data will reach each level?
2. What products will reach each level?
3. What special actions or considerations are needed for this data exchange?
4. How do we measure success?
For Limited Distribution
The following disclaimer applies: Regarding all Healthcare Fraud Prevention Partnership communications and activities, this is a purely voluntary activity. The committees regarding data sharing and analysis; information sharing; and the Executive Board, are to be used solely as discussion groups where the individual members can share facts or information or individual input. No group or consensus advice or recommendations will be given by the partners in the committees or the Executive Board. In addition, no policy-making or decision-making will be performed by the committees or the Executive Board. The
Secretary and the Attorney General or their designees will make the final policies or other decisions.
DARC - CONCEPTUAL STUDY LIFE CYCLE
Stage: Study Selection• Study Proposal• Selection Criteria• Prioritized into
Pipeline
Stage: Design & Planning• Data Design• Participating Entities• Planning Logistics
Stage: Execution & Analysis• Moderated Exchange• Aggregation & Results• Analysis• Corroboration• Iteration
Stage: Outcomes Measurement• Process &
Operational• Outcomes
For Limited Distribution
The following disclaimer applies: Regarding all Healthcare Fraud Prevention Partnership communications and activities, this is a purely voluntary activity. The committees regarding data sharing and analysis; information sharing; and the Executive Board, are to be used solely as discussion groups where the individual members can share facts or information or individual input. No group or consensus advice or recommendations will be given by the partners in the committees or the Executive Board. In addition, no policy-making or decision-making will be performed by the committees or the Executive Board. The
Secretary and the Attorney General or their designees will make the final policies or other decisions.
DARC STUDY PIPELINE AND OVERLAP WITH CONCEPTUAL STUDY LIFE CYCLE
Stage: Study Selection•Study Proposal•Selection Criteria•Prioritized into Pipeline
Stage: Design & Planning•Data Design•Participating Entities•Planning Logistics
Stage: Execution & Analysis•Moderated Exchange•Aggregation & Results•Analysis•Corroboration• Iteration
Stage: Outcomes Measurement•Process & Operational•Outcomes
Pipeline Tiger Team will:
Document Study Concepts;
Prioritize Concepts;
Recommend Studies.
For Limited Distribution
The following disclaimer applies: Regarding all Healthcare Fraud Prevention Partnership communications and activities, this is a purely voluntary activity. The committees regarding data sharing and analysis; information sharing; and the Executive Board, are to be used solely as discussion groups where the individual members can share facts or information or individual input. No group or consensus advice or recommendations will be given by the partners in the committees or the Executive Board. In addition, no policy-making or decision-making will be performed by the committees or the Executive Board. The
Secretary and the Attorney General or their designees will make the final policies or other decisions.
DARC - STUDY PIPELINE AND OVERLAP WITH CONCEPTUAL STUDY LIFE CYCLE
Stage: Study Selection•Study Proposal•Selection Criteria•Prioritized into Pipeline
Stage: Design & Planning•Data Design•Participating Entities•Planning Logistics
Stage: Execution & Analysis•Moderated Exchange•Aggregation & Results•Analysis•Corroboration• Iteration
Stage: Outcomes Measurement•Process & Operational•Outcomes
Pipeline Tiger Team will:
Coordinate Intended Study Concepts with Technical Sub Groups
For Limited Distribution
The following disclaimer applies: Regarding all Healthcare Fraud Prevention Partnership communications and activities, this is a purely voluntary activity. The committees regarding data sharing and analysis; information sharing; and the Executive Board, are to be used solely as discussion groups where the individual members can share facts or information or individual input. No group or consensus advice or recommendations will be given by the partners in the committees or the Executive Board. In addition, no policy-making or decision-making will be performed by the committees or the Executive Board. The
Secretary and the Attorney General or their designees will make the final policies or other decisions.
EARLY ACTIVITIES OF THE PARTNERSHIP
• The first information exchange has occurred (more information discussed on the next slide).
• Sharing this information is considered a major milestone in the maturation of the HFPP and tested the process for data exchange
• Participating partners are evaluating the results for use and value in their individual programs
• Participating partners were limited due to legal constraints
For Limited Distribution
The following disclaimer applies: Regarding all Healthcare Fraud Prevention Partnership communications and activities, this is a purely voluntary activity. The committees regarding data sharing and analysis; information sharing; and the Executive Board, are to be used solely as discussion groups where the individual members can share facts or information or individual input. No group or consensus advice or recommendations will be given by the partners in the committees or the Executive Board. In addition, no policy-making or decision-making will be performed by the committees or the Executive Board. The
Secretary and the Attorney General or their designees will make the final policies or other decisions.
FIRST INFORMATION EXCHANGE• 11 Partners Contributed
• 2 Federal• 1 State• 1 Private Association• 7 Private Payers
• 3 Information Types• >1400 Misused
Codes• >100 Fraud
Schemes• >44 Data Sources
• Partner analysis yielded various interesting findings
First Informat
ion Exchan
ge
Misused
Codes
Fraud Schem
es
Data Source
s
For Limited Distribution
The following disclaimer applies: Regarding all Healthcare Fraud Prevention Partnership communications and activities, this is a purely voluntary activity. The committees regarding data sharing and analysis; information sharing; and the Executive Board, are to be used solely as discussion groups where the individual members can share facts or information or individual input. No group or consensus advice or recommendations will be given by the partners in the committees or the Executive Board. In addition, no policy-making or decision-making will be performed by the committees or the Executive Board. The
Secretary and the Attorney General or their designees will make the final policies or other decisions.
EXAMPLES OF SHARED INFORMATION: MISUSED CODES & FRAUD SCHEMES
For Limited Distribution
The following disclaimer applies: Regarding all Healthcare Fraud Prevention Partnership communications and activities, this is a purely voluntary activity. The committees regarding data sharing and analysis; information sharing; and the Executive Board, are to be used solely as discussion groups where the individual members can share facts or information or individual input. No group or consensus advice or recommendations will be given by the partners in the committees or the Executive Board. In addition, no policy-making or decision-making will be performed by the committees or the Executive Board. The
Secretary and the Attorney General or their designees will make the final policies or other decisions.
THE FUTURE OF THE PARTNERSHIP
• Build the Trusted Third Party & necessary technical capabilities
• Active pipeline of studies & data exchanges• Legal agreements and other necessary policies• Identifiable data exchanges• Best practices and information sharing
• Expanded membership & fraud-fighting capabilities
For Limited Distribution
The following disclaimer applies: Regarding all Healthcare Fraud Prevention Partnership communications and activities, this is a purely voluntary activity. The committees regarding data sharing and analysis; information sharing; and the Executive Board, are to be used solely as discussion groups where the individual members can share facts or information or individual input. No group or consensus advice or recommendations will be given by the partners in the committees or the Executive Board. In addition, no policy-making or decision-making will be performed by the committees or the Executive Board. The
Secretary and the Attorney General or their designees will make the final policies or other decisions.
DATA SHARING OPERATIONAL MILESTONES
CY ‘13 Q1 CY ‘13 Q3CY ‘13 Q2 CY ‘13 Q4
De-Identified Information Sharing (i.e. Best Practices, Fraud Schemes)
Proof of Concept for Identified Information Exchange
Dat
a Sh
arin
gBu
sine
ss F
ram
ewor
kTe
chni
cal
Fram
ewor
k Launch Trusted Third PartyDevelop Trusted Third Party Strategy
Leverage Interim Trusted Third Party
Technical Prototyping
Fully established framework for identified information exchange
CMS Business Framework CMS Delegation of Authority – Authority for CMS to exchange information with private partners CMS System of Record Notice – Requirement for aligning CMS systems with data exchange needs CMS Umbrella Paperwork Reduction Act Clearance – Permits expansion beyond 9 private
participating entities
Partner and Participating Entity Framework Memoranda of Understanding – Establishes principles of the partnership Business Associate Agreements – Legal agreements to allow sharing of identified data
For Limited Distribution
The following disclaimer applies: Regarding all Healthcare Fraud Prevention Partnership communications and activities, this is a purely voluntary activity. The committees regarding data sharing and analysis; information sharing; and the Executive Board, are to be used solely as discussion groups where the individual members can share facts or information or individual input. No group or consensus advice or recommendations will be given by the partners in the committees or the Executive Board. In addition, no policy-making or decision-making will be performed by the committees or the Executive Board. The
Secretary and the Attorney General or their designees will make the final policies or other decisions.
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