Performance Management

The Determine Adverse Action Incident business process receives an incident from an investigative unit with the direction to pursue the case to closure. The case may result in civil or criminal charges, corrective action, removal of a provider, contractor, trading partner or member from the Medicaid Program, or the State Medicaid Agency (SMA) may terminate or suspend the case. Individual state policy determines what evidence is necessary to support different types of cases: • Provider utilization review • Provider compliance review • Contractor utilization review (includes managed care organizations) • Contractor compliance review • Member utilization review • Investigation of potential fraud or abuse review • Drug utilization review • Quality review (e.g., Consumer Assessment of Healthcare Providers and Systems (CAPHS) and Healthcare Effectiveness Data and Information Set (HEDIS) measures) • Performance review (e.g., Key Performance Indicator (KPI)) • Contract review • Erroneous payment review • Audit Review • Other evaluation of information Different criteria and rules, relationships, and information define each type of adverse action incident and require different types of external investigation.

The Establish Compliance Incident business process is responsible registration of a case for incident tracking of utilization anomalies. It establishes an incident file, generates incident identification, assigns an incident manager, links to related cases, and collects related documentation.

The Identify Utilization Anomalies business process uses criteria and rules to identify target groups (e.g., providers, contractors, trading partners or members) and establishes patterns or parameters of acceptable and unacceptable behavior, tests individuals against these models, or looks for new and unusual patterns, in order to identify outliers that demonstrate suspicious utilization of program benefits. Internal and external referrals, business intelligence analysis (i.e., historical, current, and predictive views of business operations), and scheduled or on-demand reporting may identify a compliance incident. Identification of utilization anomalies include evaluation of: • Provider utilization review • Provider compliance review • Contractor utilization review (includes managed care organizations) • Contractor compliance review • Member utilization review • Investigation of potential fraud or abuse review • Drug utilization review • Quality review (e.g., Consumer Assessment of Healthcare Providers and Systems (CAPHS) and Healthcare Effectiveness Data and Information Set (HEDIS) measures) • Performance review (e.g., Key Performance Indicator (KPI)) • Erroneous payment • Contract review • Audit Review • Other evaluation of information Different criteria and rules, relationships, and information define each type of compliance incident and require different types of external investigation.

The Manage Compliance Incident Information business process is responsible for the monitoring of incidents of utilization anomalies. Activities include referring (e.g., escalation) incident to another incident manager or agency, modifications to incident information, journaling activities, and disposition of incident.

The Prepare REOMB business process is responsible for the creation of Recipient Explanation of Medicaid Benefits (REOMB) for detecting payment problems. The State Medicaid Agency (SMA) sends the REOMB to randomly selected members of Medicaid services. It gives information on the Medicaid services paid on behalf of the member. The communication includes the provider's name, the date(s) of services, and the payment amount(s). Instructions on the communication tell the member what to do if the provider did not actually perform any of the listed services billed directly to him/her by the provider. NOTE: This business process does not include the handling of returned information.