OM04 Apply Attachment 1 Attachments must be submitted with a paper claim. The attachment and the claim are imaged and stored in electronic format. There is no way currently to receive an electronic attachment at the present time. Validation of the attachment is a manual process. The satisfaction of the stakeholder is fairly high but it still rated at a level 1. OM05 Apply Mass Adjustment 1 The paper form or list of transactions is entered for adjustment processing which can take several working days to complete. This process is inaccurate and inefficient. Stakeholders’ satisfaction is low due to delays and inconsistencies that are produced in the Mass Adjustment process. OM06 Edit Claim/ Encounter 1 No sister agency uses the MMIS edit claim process. There is some integration of Claims editing process across the whole Medicaid Enterprise. There are some instances where suspended claims may take days to resolve. The cost effectiveness of the process is low due to high effort needed to change some business rules. Many changes to the edit program may be made via table configuration but some may require coding changes. Stakeholder satisfaction is still at a level 1 but continued effort toward improvement should move this to the next level. OM07 Audit Claim/Encounter 1 Some validations are automated while others require manual review. Any change in business rule requires maintenance that is time consuming and costly. Suspended transactions require many days to resolve. Stakeholder satisfaction appears not to be measured and therefore is considered low. OM08 Price Claim/Value Encounter 2 The majority of Medicaid services are priced automatically. DMS and its vendors use reference data or commercial sources to assign a price to a claim or value an encounter. Pricing changes are made easily to the systems. MMIS is able to support multiple waiver and a-typical programs. The satisfaction of stakeholders and agency staff is greater than a level 1.
OM15 Prepare Capitation Premium Payment 1 The process is automated but there is manual intervention in places. State specific business rules have been automated for most situations. Payment calculations are performed nightly during batch processing. Accuracy and consistency is performed at a fairly high level due to the level of automation. Stakeholders’ satisfaction is fairly high. OM16 Prepare Health Insurance Premium Payment 1 The Prepare Health Insurance Premium Payment process is a manual process. The process requires at least 30 days to complete. Access to the data is very limited. The cost effectiveness of the process is low due to the lack of automation. Stakeholders’ satisfaction is very low and there are many issues associated with the process. OM17 Prepare Medicare Premium Payment 2 There is a mix of both automated and manual processes. DMS exchanges information with SSA via electronic interfaces based on HIPAA standards. The process requires fewer than 10 days to complete. Stakeholders’ satisfaction is fairly high. OM18 Inquire Payment Status 2 Requests are received by the Fiscal Agent (FA) through paper, phone, fax, email, AVRS, and web portal. Current process is a mix of automated and manual steps. Support X12 276/277 transactions Stakeholder satisfaction is good. OM19 Manage Payment Information 2 The Manage Payment Information business process is meeting the needs of managed care and waiver programs. Payment history updates continues to be scheduled around MMIS production cycles Data sources are primarily electronic. Stakeholder satisfaction is good.
Figure 7: Program Integrity Management Summary The primary factors affecting maturity ratings across the Program Integrity Management business area include the following: Data retrieval is automated; data analysis is a mix of manual and automated steps Case identification is not standardized and comes from multiple sources Internal referrals are paper based and communicated manually Impact of Managed Care on Program Integrity Management The switch to a dual-model with the bulk of the members enrolled in a MCO will have the following impacts on the Program Integrity Management business area. Fraud prevention becomes a shared responsibility with the MCOs Case identification and case management activities reduce due to the drop in FFS claims. Business Capabilities Matrix This section articulates the maturity level of the individual business processes within the Program Integrity Management business area for the Medicaid Enterprise. While all MITA Framework 2.01 capabilities will be addressed for each target maturity level, the table below focuses on the key rationale to support the maturity level determinations. Table : Program Integrity Process Summaries mita business process As Is maturity level As Is Process Description – Program Integrity Management PI01 Identify Candidate 1 Data and policy analysis is a mix of manual and automated steps. The process is duplicated in multiple parts of the organization Case tracking is manual. Case identification is not standardized. Internal referrals are paper based. PI02 Manage Case 1 Process is a mix of manual and automated steps. The process is duplicated in multiple parts of the organization Data is evaluated manually. Case tracking is manual. Internal referrals are communicated manually.
PG04 Develop Agency Goals and Objectives 1 The process has some automation to enable it to be more efficient. Spreadsheets are used to track the process. Medicaid’s upper management consults with other agency heads to form goals and objectives. The accuracy of this business process is good and up to date. Stakeholder satisfaction with this business process is high and has increased to a level 2. PG05 Develop and Maintain Program Policy 1 Process is duplicated in multiple parts of the organization. Policy development is a manual process which impacts the accuracy of the results. Access to data is limited. PG06 Maintain State Plan 1 Revisions in the State Plan are transmitted to CMS via email. The State Plan does not reside on the DMS portal An internal tracking sheet is used to make sure the management chain is aware of changes involving the State Plan. DMS does collaborate with other state agencies when modifying the State Plan. The process of maintaining the State Plan meets state objectives. It also meets state and federal guidelines. Stakeholders’ satisfaction with the process is negatively impacted by the manual nature of the current process. PG07 Formulate Budget 1 The process is a mixture of manual and automated processes. The state meets current standards and data comes from multiple sources in standard formats. Data used in the process is verified in both manual and automated ways. The majority of the information comes from the Decision Support System (DSS), MMIS and Electronic Medical Administration Record (eMAR). The stakeholders are pleased with the final outcome.