Agenda

Date and TimeTitle
Aug 8, 2022
8:30am - 8:55am (Eastern)
NAMPI Welcome (Plenary)

After 2 years of virtual conferences, the Board welcomes everyone back to the NAMPI conference!

Aug 8, 2022
8:55am - 9:45am (Eastern)
Let's All Just Get Along: Building Partnerships Through Humor (Keynote Plenary)

With her incredibly humorous and relatable style, Christine gives you the tools to identify, understand and approach conflict creatively. Attendees will discover the secrets to defuse anyone in any situation, blow off steam before you boil over, and bring peace to all across the land. Christine’s conflict and teamwork program is a wonderful interactive session, sure to help attendees identify, understand and approach conflict creatively.

Aug 8, 2022
9:45am - 10:10am (Eastern)
Welcome from Baltimore PI (Plenary)

Welcome from Maryland Program Integrity

Aug 8, 2022
10:40am - 11:25am (Eastern)
From French Fries to Fraud (State/Federal Breakouts Block 1)

Case study of an optometrist and a dentist who created a scheme involving kickbacks of free rent for referrals of children within their offices, transportation of children from schools to the offices for treatment, and the various forms of Medicaid fraud performed by each provider involving the children.

Aug 8, 2022
10:40am - 11:25am (Eastern)
Federal/State Partnerships to Enhance Oversight of State Medicaid Programs Including a Case Study of Beneficiaries Concurrently Enrolled in Multiple States (State/Federal Breakouts Block 1)

HHS/OIG has developed a partnership plan involving OIG and State oversight groups aimed at preventing and detecting improper payments. This session will provide an overview/history of OIG efforts involving partnerships with State oversight groups, including past successes and a discussion of recently completed partnership audits involving the OIG and State auditors from Massachusetts, New York, and Oregon. During the session, we will also highlight an ongoing partnership opportunity for program integrity units that is focusing on a high-risk area. Specifically, we will focus on significant Medicaid improper payments that States are making to managed care organizations for beneficiaries who are concurrently enrolled in multiple State Medicaid programs.

Aug 8, 2022
10:40am - 11:25am (Eastern)
Auditing with a Firm Foundation (State/Federal Breakouts Block 1)

Ensuring Program Integrity departments have appropriate language in their policies & procedures, their case management requirements are clearly outlined, understood, and implemented prior to auditing. When you are ready to audit, draw from the instructions given to build an audit tool. Define your audit, give notification, and then see how the requirements seemed so clear to you, but not the MCE! What do you do? How do you corral case audits? Going with your gut when the audit goes south.

Aug 8, 2022
10:40am - 11:25am (Eastern)
Not Always a Positive Change: A Behavioral Health Case Study (State/Federal Breakouts Block 1)

A case discussion regarding a mental health rehabilitation provider and the steps taken in the case. Beginning with the receipt of the initial complaint in Feb. 2017 through the sentencing in April 2022, including a search warrant executed in Nov. 2017. This case includes falsification of patient notes, to including creation of entire patient charts by cutting and pasting documents together, billing for services not rendered and paying recipients to enroll with the provider.

Aug 8, 2022
11:35am - 12:20pm (Eastern)
How Missouri Leveraged Analytics to Identify Priority Targets, Reduce Investigation Time and Recover More Dollars (Sponsor Breakout Block 1 - Alivia Analytics)

The Missouri Medicaid Audit and Compliance Unit (MMAC) within the Missouri Department of Social Services (DSS) recently implemented a new solution to help investigators and auditors identify, recover and prevent inappropriate payments in a more efficient and robust manner. By putting advanced analytics in the hands of the MMAC team, they can now build more accurate, confident and efficient investigative and audit plans. The State has been able to use the new MMAC solution to address the following State Goals: 1. Increase FWA Leads: Increase the number of actionable FWA leads for MMAC program integrity staff to audit and/or investigate 2. Increase Areas of Risk Reviewed: Increase the number of FWA scenarios reviewed for risk 3. Increase Medicaid Dollars Recovered: Increase the total amount of improperly paid Medicaid funds recovered 4. Increase ROI: Increase the Return on Investment (ROI) for MMAC

Aug 8, 2022
11:35am - 12:20pm (Eastern)
Program Integrity Implications for Federal Unwinding Implementation and Beyond (Sponsor Breakout Block 1 - KPMG LLP)

As the COVID-19 Public Health Emergency (PHE) unwinding begins, both states and the Federal government need to manage downstream policy and operational implications of the pandemic-related policy changes and subsequent reversals. During this session, panelists will provide an overview of common trends and issues observed in response to the various waivers that put into place - including eligibility and enrollment, provider accreditation, and telehealth – as well as explore each of these themes through the lens of health equity. Panelists will also share examples of how they have supported states in managing operational challenges, and how future program integrity (PI) activities can be informed by lessons learned from the PHE, from both state and Federal perspectives.

Aug 8, 2022
11:35am - 12:20pm (Eastern)
A Comprehensive and Streamlined Approach to Program Integrity (Sponsor Breakout Block 1 - Gainwell)

As we emerge from the recent COVID-19 pandemic, challenges continue to multiply – and complicate – the healthcare ecosystem. For example, more enrollees have joined Medicaid programs, disenrollment’s have been on hold, healthcare spending continues to rise, and new COVID-related fraud schemes have emerged as added threats. In light of these challenges, the time is now to re-evaluate how well your Program Integrity (PI) efforts drive real-world value and support the entire healthcare continuum. Specifically, you can take your PI program to the next level by developing a comprehensive approach to address every aspect of your healthcare environment, harnessing the power of new approaches to obtain and leverage non-traditional data sources and advanced analytics. In this session, we will share real-world best practices and results for identifying and implementing a robust PI design using the strength of technology to maximize program success and optimize program dollars. Additionally, these insights can help drive and inform policy changes while also improving health outcomes as we emerge from the pandemic.

Aug 8, 2022
1:15pm - 2:00pm (Eastern)
Update on OIG Healthcare Fraud Trends (Plenary)

This session is an overview of fraud trends (law enforcement actions) identified by HHS-OIG as well as priorities of focus the organization is dedicating resources to.

Aug 8, 2022
2:10pm - 2:55pm (Eastern)
Data Initiative Project Team (DIPT): Pursuing Provider Investigations Through Data Initiatives (State/Federal Breakouts Block 2)

Presentation on the Texas HHS-OIG Data Initiative Project Team (DIPT) created to identify provider overpayments by relying on data to pinpoint provider errors. Attorneys and investigators identify a practice or error with a substantial data proof component. By using encounters and paid claims data, the DIPT develops and pursues a test case from investigation through provider notice and negotiation. The process is then “templated,” to ensure the same conduct and similar cases are handled consistently. Investigators are then trained in the process to follow and depending upon the overpayment amounts, cases are opened and assigned to investigators to pursue by following the template and process.

Aug 8, 2022
2:10pm - 2:55pm (Eastern)
Providing Automation and Efficiency to Managed Care Program Compliance - MCO Document Tracking Tool (State/Federal Breakouts Block 2)

A primary issue facing states is an inefficiency around tracking the required reports and artifacts that are required for submission to the state by the Managed Care Organization (MCO). To resolve this issue, the Commonwealth of Kentucky is using a MCO document tracking tool that tracks submission of documents and data from MCOs. Analysts can select and configure/deselect features within the tool as needed for their specific needs (reports selected and their frequencies, for example). The Commonwealth’s Tracker includes more than 70 report definitions and provides analysts with key information about MCO timeliness and quality of submissions. The tool provides a mechanism for tracking in real time and automates the report content validation process. Join us to learn about this tool and how it provides efficiency to users

Aug 8, 2022
2:10pm - 2:55pm (Eastern)
Is Presuming Definitive or Is Definitive Presuming?: A Laboratory Urinalysis Case Study (State/Federal Breakouts Block 2)

This presentation examines the logic OMIG-State of Arkansas used in conducting this audit focusing on urinalysis for drug testing. We will also look at how OMIG interpreted the definitions of presumptive and definitive lab testing during the performance of this case study audit. We will discuss the providers’ responses to the audit. Participants will have the opportunity to express how they might have interpreted the findings of this case study.

Aug 8, 2022
3:15pm - 4:00pm (Eastern)
Analytics and Beyond: Algorithms, Workflow Management, Reporting Outcomes and ROI (Sponsor Breakout Block 2 - IBM)

State program integrity teams have continued to advance their capabilities and improved both the effectiveness and efficiency of their fraud detection and prevention efforts. Through case studies from around the country, learn how state peers have been applying analytics, leveraging AI, automating workflows, strengthening program oversight, and tracking results and outcomes. Missouri will share how they are applying the comprehensive capabilities of their enhanced FADS/PI solution to initiate and manage cases and measure results, including lessons learned for states preparing to meet the recently updated requirements for modular CMS certification. Report results are only the beginning.

Aug 8, 2022
3:15pm - 4:00pm (Eastern)
ABA Therapy and Overlapping Services (Sponsor Breakout Block 2 - Codoxo)

Applied Behavioral Analysis [ABA] therapy is the behavioral treatment most used with children diagnosed with Autism Spectrum Disorder [ASD]. ABA is designed to help children improve his or her various functional skills, including, but not limited to, social skills, communication, daily living, controlling emotional responses, and develop positive behaviors. Medicaid benefits for ASD treatment and the available services differ from state-to-state as well as regionally for school systems. These variances in coverage can create challenges in continuing quality care of an autistic child, especially for parents and patients moving between states, or school systems. Certified ABA therapists [BCBA’s] are allowed to train and manage staff to follow their ABA treatment protocols, which may include Registered Behavior Technicians and Assistant Behavioral Analysts pursuing a BCBA certification. While this a commonly accepted practice, the claims traffic may not identify the actual rendering ABA therapist and cumulative claims data may suggest unlikely or impossible hours per date of service. Some ASD patients may need additional treatments, such as speech [ST], physical [PT] and occupational therapy [OT]. Efforts to coordinate care with ST, PT or OT providers may lead to overlapping services or concurrent treatment during ASD treatment. This session will help NAMPI attendees develop claim and patient analysis methods, resources to research an ABA practitioner and their business model, and best practices to review patients and providers related to ABA therapy.

Aug 8, 2022
3:15pm - 4:00pm (Eastern)
Insights and Analytics for Conducting Successful Hospice Audits (Sponsor Breakout Block 2 - Qlarant)

This session will explore Qlarant’s lessons learned while conducting hospice audits. The session will also provide audit insight and analytic solutions that will assist State staff in conducting successful hospice audits.

Aug 9, 2022
8:30am - 8:50am (Eastern)
NAMPI 2022 Day Two Remarks and Business Meeting (Plenary)

NAMPI 2022 Day Two Remarks and Business Meeting

Aug 9, 2022
8:50am - 9:20am (Eastern)
Center for Program Integrity Overview and Priorities for Protecting Medicare and Medicaid(Plenary)

This session will provide a high level overview of the Center for Program Integrity's (CPI) mission, scope of work, and priorities in light of the Secretary’s Strategic Plan.

Aug 9, 2022
10:45am - 11:30am (Eastern)
Auditing Financial Statistical Reports, Managed Care Organization Reimbursements to Pharmacy Benefit Managers, and Rate Setting Impacts (State/Federal Breakouts Block 3)

This presentation will detail work done by the Texas Health and Human Services (HHS) Office of Inspector General (OIG) Audit and Inspections Division in performing audits of managed care organization (MCO) financial statistical reports (FSRs) and MCO payments to pharmacy benefit managers (PBMs), including how audit results can impact the experience rebate and rate setting process. The session will include an explanation of FSRs, the reimbursement process to PBMs, typical findings from FSR and PBM audits, an overview of the rate setting process, and information about how audits can affect experience rebate calculations and rate setting.

Aug 9, 2022
10:45am - 11:30am (Eastern)
Behavioral Health - Sometimes Provided by Dentists, Real Estate Brokers and Cosmetologists (State/Federal Breakouts Block 3)

This session will start with a presentation going over case examples from Florida and current schemes in the behavioral health program. This will include several specific providers and many schemes. The presentation will include an overview of relevant procedure codes and program integrity issues related to those codes. The presentation portion will wrap up with enrollment related issues, as eluded to in the title. The session will continue with a round table discussion of key issues found when interviewing providers involved in these schemes, some knowingly and some unknowingly.

Aug 9, 2022
10:45am - 11:30am (Eastern)
Understanding and Using Mental Health Electronic Records to Detect Fraud (State/Federal Breakouts Block 3)

Electronic Mental Health Record (EHR) and Electronic Medicaid Record (EMR) software, also know as behavioral health software, allows physicians, therapists and other clinical professionals to manage their clinical and administrative workflows. The software also manages patient caseloads, patient outcomes, and ensures regulatory compliance for providers. EHR/EMR software, however, has several capabilities that can be exploited for use in health care fraud investigations. Examples of such capabilities are (1) management information concerning patient treatment/interactions, (2) encounter records documenting specific interactions with patients, and (3) billing and coding information associated with treatment of patients by providers. This presentation by an investigator from the District's Medicaid Program's Division of Program Integrity (DPI) and two District Medicaid Fraud Control Unit agents will show how these two District government agencies have "partnered" and worked together to identify fraud in the Medicaid program by using EHR/EMR software. The DPI investigator is a former behavioral health counselor and will discuss how she used the software to record her interactions with patients as a counselor, and how she currently uses the software in her present role as a fraud investigator. The three panelists will demonstrate to the audience how they manipulate the software to identify providers that appear to be over-billing or incorrectly billing the Medicaid program. The presentation will use slides illustrating how the software is supposed to be used, and slides showing how they have manipulated the software as an investigative tool. The investigators use the software to identify fraud but also use the software in all facets of their investigations, including preparing for interviews with providers, estimating fraud loss amounts, and linking EHR/EMR billing records with fraudulent claims submitted to the Medicaid program. This presentation is not a case study, but case examples will be used by the panelists to highlight their discussion.

Aug 9, 2022
11:40am - 12:25pm (Eastern)
Rooting Out Multi-party FWA Through Network Analysis (Sponsor Breakout Block 3 - Deloitte)

This session will demonstrate the use of network analysis and graph analytics to assist in the indentification of multi-party FWA. The presenters will discuss key approaches to consider when evaluating provider and patient relationships; including geographic location, provider communities, and patient access to care.

Aug 9, 2022
11:40am - 12:25pm (Eastern)
It's the Provider: New Integr8 AI Technology to Stop FWA Before It Happens (Sponsor Breakout Block 3 - 4L Data Intelligence)

A new patented AI technology powers a unique approach to real-time, pre-adjudication FWA prevention proven to deliver 2 to 10 times more FWA detection through new levels of upfront and continuous provider insight. The key is a technology platform based on a dynamic provider-centric approach versus the traditional claims centered approaches used by rules-based and use-case based claims editing platforms. And the Integr8™ AI platform automates and replaces much of hunt-and-seek documentation work Program Integrity units do today with real-time automated integrity alerts and a user-friendly dashboard solution for claims-specific, provider-specific and collusion network-specific data lookups.

Aug 9, 2022
11:40am - 12:25pm (Eastern)
"Four Former Federal and State Medicaid Program Integrity Managers Walk into a Conferenceā€¦" (Sponsor Breakout Block 3 - Thomson Reuters)

You’re a professional who is responsible for identifying and investigating Medicaid fraud, waste, and abuse, and you’re making the best of an ever-changing environment, often with tools that have not adapted to new threats. Fraudsters are continuously evolving their tactics. That’s why now more than ever, organizations need a dynamic, risk-based approach. Combining our expertise with the breadth and depth of our data and AI-powered analytics, together we’re helping you solve some of the most pressing challenges facing your Medicaid program. Join four former federal and state Medicaid program integrity managers to talk candidly about how you can tip the balance back towards those doing good in the world.

Aug 9, 2022
11:40am - 12:25pm (Eastern)
Anything You Can Do, AI Can Do Betterā€¦or Can It? (Sponsor Breakout Block 4 - Shift Technology)

With an average of 10 new genetic tests brought to market each day, it’s a challenge to keep track of all of the moving parts involved in genetic testing and surrounding activities. From staying on top of CMS coding updates, to managing complex lab networks, investigators take on a heavy workload to detect and prevent these schemes. Artificial Intelligence vs Manual Investigation. What is the best tool for investigators to take on genetic testing fraud? Hear experts from Integrity Advantage and Shift Technology discuss strengths and opportunities of these approaches.

Aug 9, 2022
1:30pm - 2:15pm (Eastern)
CMS Priorities: State PI Reflections (Plenary)

During this sesssion, the NAMPI Board will reflect on CMS' vision and priorities and what they might mean for state leaders, the state/federal partnership, and the Medicaid program integrity efforts. Nebraska's Program Integrity Administrator, Anne Harvey, will moderate this engaging and interactive panel discussion and invite questions and feedback from the audience.

Aug 9, 2022
2:15pm - 3:00pm (Eastern)
Protecting Medicaid Through the Federal and State False Claim Acts (Plenary)

This presentation will cover (1) the background, history, and success of the federal False Claims Act; (2) a general overview of various state False Claims Acts; (3) the substantive provisions of the federal False Claims Act, including liability, damages, and qui tam provisions; (4) how False Claims Act cases are evaluated and investigated; and (5) suggestions on how state officials can get involved with False Claims Act cases.

Aug 9, 2022
3:30pm - 4:15pm (Eastern)
Fighting Member Fraud, Waste and Abuse via a Data Broker Model (Sponsor Breakout Block 4 - PCG)

In recent years, several states have engaged independent vendors to manage their access to third-party verification data via a single interface. Consolidating this access provides states with the flexibility to make this data available in single location, accessible to both eligibility operations and program integrity staff, for both predefined and ad hoc use. In this session, we will review the creative ways three states are taking advantage of their centralized verification data “hubs” to prevent fraud, improve error rates, and expedite eligibility determination timeframes. Speakers will: - Educate attendees on the Data Broker Model being employed by these states and how it fits into their operational and investigative workflows - Highlight the creative ways both program integrity and eligibility operations staff are taking advantage of this centralized access to third-party data - Review novel approaches to limiting Data Broker integration time, resource requirements, and hassle - Introduce advances in commercial verification data and new and unique applications and exchanges of the data

Aug 9, 2022
3:30pm - 4:15pm (Eastern)
The Path to Modernizing Our FWA Capabilities (Sponsor Breakout Block 4 - KPMG)

Discussion of the TennCare Office of Program Integrity’s (OPI) objectives in leveraging advanced technology to enhance Medicaid fraud detection, prevention, and related case management oversight capabilities, with a focus on how we developed and executed on our strategy. OPI utilized both internal and external resources and partners to embark on the journey of transforming our approach and procuring a technology solution that meets CMS’s requirements for certification. One of the primary goals of this session is to share our experience with other states who might benefit from leveraging aspects of our process to assess and enhance their own approach in line with their objectives. The session will emphasize the various steps in our process, from conducting a current state/gap assessment, to defining a strategy, procuring a solution, and how we leveraged internal and external resources to support our Program Integrity goals.

Aug 9, 2022
3:30pm - 4:15pm (Eastern)
Are You a Program Integrity Superhero? (Sponsor Breakout Block 4 - SAS)

Program integrity has always championed health equity and quality of care. That makes you a superhero! This session will teach you how to tell your superhero story and why program integrity is always relevant. We will learn about the connections between health equity and fraud, waste, and abuse, and we’ll discuss why program integrity is an important leader in this space. We will reconsider access to care through a health equity lens and why it changes the conversations that you’ve been having with program and policy staff. We will better understand how data analytics is the program integrity superhero’s secret weapon, tackle data ethics, and dispel misconceptions about bias in analytics and the use of artificial intelligence for health care fraud, waste, and abuse. SAS has always emphasized centering technology around people to ensure a positive impact on our society, from our program #dataforgood to the recent appointment of SAS’ Reggie Townsend, Director of the Data Ethics Practice, to the National Artificial Intelligence Advisory Committee (NAIAC). The NAIAC will advise the President and the National AI Initiative Office on a range of issues related to AI. SAS continues to lead the way for superheroes like you!

Aug 9, 2022
3:30pm - 4:15pm (Eastern)
NHCAA: How We Can Help (Sponsor Breakout Block 3 - NHCAA)

The National Health Care Anti-Fraud Association has served as a reliable convener of private and public partners united against health care fraud for the last 37 years. Join us to learn more about NHCAA and the tools, resources, and opportunities we have to offer.

Aug 10, 2022
8:30am - 8:35am (Eastern)
NAMPI 2022 Day Three Remarks (Plenary)

NAMPI 2022 Day Three Remarks (Plenary)

Aug 10, 2022
8:35am - 9:15am (Eastern)
Everything You Need to Know About MFCUs (Plenary)

The session focuses on an overview of MFCUs, NAMFCU, and the role of Program Integrity in MFCU investigations, collaboration ideas, and trends.

Aug 10, 2022
9:15am - 10:00am (Eastern)
Perspectives on Prevention of Fraud, Waste and Abuse from States Large to Small (Plenary)

Like most things, Program Integrity adapts to its environment. Depending on the overall budget, Medicaid participants, staff size, and more, our systems and processes can look very different from others. Attendees can expect to leave with overviews from each panelist on their FWA efforts and what Program Integrity looks like in their state/territory including balancing proactive vs. reactive measures.

Aug 10, 2022
10:15am - 11:00am (Eastern)
Ongoing Public Health Emergencies: Fraud, Waste and Abuse Related to COVID-19 and the Opioid Crisis (State/Federal Breakouts Block 4)

The discussion will focus on current Healthcare Fraud Prevention Partnership (HFPP) data analytics, highlighting providers who have high potential exposure dollars with a concentration on studies related to ongoing public health emergencies (PHEs): COVID-19 and the Opioid Crisis. The presentation will review how to utilize HFPP study results to identify providers seeking to take advantage of regulatory and system flexibilities during the COVID-19 PHE by billing expensive, unnecessary tests in conjunction with COVID-19 diagnostic tests. Of particular concern are respiratory pathogen panels (RPPs), genetic tests, respiratory tests other than COVID-19 tests, and COVID-19 antibody tests billed with COVID-19 diagnostic tests. In addition, to the ongoing COVID-19 PHE, the presentation will highlight providers who continue to over-prescribe opioids resulting in opioid misuse, abuse, and overdoses.

Aug 10, 2022
10:15am - 11:00am (Eastern)
Results of a Successful Partnership (State/Federal Breakouts Block 4)

When the MFCU and the Single State Agency work together, the relationship fosters results. We will discuss how the dynamic relationship between the Massachusetts MFCU and Single State Agency has changed over time, including expanding to include external parties like managed care entities. Lastly, we will walk through the life cycle of a case, from pre-referral to referral and how it progresses through litigation (both criminal and civil) to show how an effective partnership can improve case outcomes

Aug 10, 2022
10:15am - 11:00am (Eastern)
A Comprehensive Approach to Stopping Behavioral Health Medicaid Fraud (State/Federal Breakouts Block 4)

The nature of behavioral health fraud is inherently elusive to investigations and prosecutions. Successful investigations of this particular genre require an extraordinarily collaborative effort across several separate state and local agencies. In this presentation, the Arizona MFCU and AZ Medicaid Agency (AHCCCS) aim to provide a generally applicable framework for sister jurisdictions to stop and prevent this illicit, highly lucrative enterprise. Over the course of the last two years Arizona has enjoyed success in both civil and criminal arenas using this collective approach. From developing data algorithms in line with policies, procedures and criminal statues, to search warrants and other investigative tools, the AZ Team has achieved continual advancements in prosecution and financial recoveries. Our principal goal: provide information derived from our experience in Arizona, though both trial and error, such that your civil and criminal prosecution of behavioral health fraud is successful.

Aug 10, 2022
11:10am - 12:00pm (Eastern)
NAMPI Regional Updates (Plenary)

NAMPI Regional Updates (Plenary)

Aug 10, 2022
12:00pm - 12:30pm (Eastern)
Cooking with Kelly and Closing Remarks (Plenary)

Join us in Kelly's kitchen to see what she's cooking up this year!