Instrument Track Changes from 60-day to 30-day

Appendix B

SPIA Data Collection Instrument

FFY 2007

Contact Information
1		State:		     
2		Name:		     
3		Title		     
4		Phone number:		     
5		E-mail:		     
Program Characteristics
6		Medicaid Enrollment:		Fee-for-service recipients:       Managed care enrollees: Fee-for-service:       Primary care case management:       Total:      
7		Estimate of expendituresOrganizational structure for Medicaid Integrity activities ($):within the State:		      Distinct Program Integrity Model Inspector General (IG) Model Hybrid Model
8		Organizational structure for Medicaid Integrity activities within State:Activities that the State includes under the scope of Medicaid Integrity:		Distinct Program Integrity ModelAudits Inspector General (IG) ModelInvestigations Hybrid ModelSURS/Data Mining Provider Enrollment Provider Education/Communications Managed care oversight Other, please specify:      
9		Activities that the State includes under the scope of Medicaid Integrity: Medicaid Integrity activities that the State contracts out:		Audits Investigations SURS/Data Mining Provider Enrollment Provider Education/Communications Managed care oversight Other, please specify:      
10		Estimate of expenditures for Medicaid Integrity activities that the State contracts out($) Audits: Investigations: SURS/Data Mining: Provider Enrollment: Provider Education/Communications: Managed care oversight: Other: Total:		Audits Investigations SURS/Data Mining Provider Enrollment Provider Education/Communications Managed care oversight Other, please specify:                                                
11	Number of Managed Care Organizations (MCOs) in State:		     
Planning
Staffing
1211		Total number of FTEs by type of position (e.g., Auditor, SURS Analyst)(filled and vacant) for all functions considered to be Medicaid Integrity: (List each position type & corresponding # of FTEs)		(Position type)Audits: Filled:       (Position type) Vacant:       (Position type)Investigation: Filled:       (Position type): Vacant:       (Position type)SURS/Data Mining: Filled:       Vacant:       Provider Enrollment Filled:       Vacant:       Provider Education/Communications: Filled:       Vacant:       Other:       Filled:       Vacant:      
IT Resources
1312		Inventory of IT resources used to conduct Medicaid Integrity activities: (check all that apply)		SURS I SURS II Advanced SURS RAMS II PC-based SURS CS-based SURS Fraud and Abuse Detection System Decision Support System Ad-hoc reporting Managed care encounter data system Other, please specify:      
14	Estimated expenditures ($) for IT resources:		     
Strategic Planning
1513		Does the State have a documented strategic plan to address Medicaid Integrity:		For its FFS program(s)? Yes No Briefly describe:       For its managed care program(s)? Yes No Briefly describe:      
1614		(If yes to Q15Q13) How frequently are updates made to the strategic plan?		For FFS program(s)? Quarterly Yearly Bi-annually Other, please specify:       For managed care program(s)? Quarterly Yearly Bi-annually Other, please specify:      
Prevention
Provider Enrollment
1715		Total number of participating Medicaid providers:		     
1816		PercentageNumber of providers that applied for enrollment, but were denied: in Medicaid during FFY:		     
1917		Percentage of providers dis-enrolled involuntarily for reasons related to billing or other misconduct:Number of providers denied enrollment in Medicaid during FFY:		     
2018		Pre-enrollment screening conducted on individuals/entities applying for Medicaid provider numbers: (check all that apply)		In-state licensing board Out-of licensing board HHS OIG’s List of Excluded Individuals and Entities (LEIE) GSA’s Excluded Parties List System National Practitioners Data Bank Health Care Integrity Protection Data Bank Choice Point or Lexis-Nexis reviews On-site visits Criminal background investigations Credentialing Payroll Tax Records Check if provider has another provider number under which the provider made inappropriate payments Other (please specify):      
2119		Does the State maintain its own list of providers who have been involuntarily dis-enrolled? (If yes to Q19) How is the list maintained? Is the list available to the public? (If yes to Q19b) Please provide web address for the list:		Yes No Paper Web Other, please specify:       Yes No      
2220		Does the State have written policies giving direction to providers and managed care entitiesorganizations on the types and frequency of screenings they should conduct on sub-entities? (e.g., owners, managing employees)?		Yes (If yes, provide applicable policy/contractual language):       No
2321		Does the State include language in its MCO contracts specifying Medicaid Integrity requirements?		Yes (If yes, provide applicable contractual language):       No
Third Party Liability (TPL) Program
2422		Does the State include TPL as part of its Medicaid Integrity activities?		Yes No
2523		Does the State include TPL recoveries as part of its Medicaid Integrity return-on-investment?		Yes No
Prior Authorization
2624		Does the State include prior authorization as part of its Medicaid Integrity activities?		Yes No
2725		Does the State include prior authorization cost avoidance as part of its Medicaid Integrity return-on-investment?		Yes No
Provider Education
2826		Mechanisms used to communicate to and educate providers about Medicaid Integrity: (check all that apply)		Fraud, waste, and abuse policy statements Anti-fraud public service announcements Speeches made by SMAState Medicaid Agency administrators or staff to stakeholder organizations about Medicaid fraud, waste, and abuse. News releases from SMAState Medicaid Agency about managing Medicaid fraud, waste, and abuse Publications related directly to concerns of Medicaid fraud, waste, and abuse. Website dedicated to Medicaid Integrity regulations, policies, and procedures. Other (please describe):      
Detection
2927		Does the State have written policies regarding issues including, but not limited to:		How the State should investigate fraud, waste, & abuse? Yes No How to secure evidence in a legally admissible form? Yes No How and when to refer to the MFCU? Yes No How to initiate recovery action and evidence necessary to initiate recovery action? Yes No How to disseminate lessons learned from the case? Yes No
3028		Data mining techniques used to detect Medicaid fraud, waste, & abuse or inappropriate payments: (List & describe)Data repository platform used for data mining:		Mainframe Internal/external relational database (e.g., Oracle) Vendor proprietary database Name:       Mainframe data downloads to a personal computer (PC) Commercial/off-the-shelf PC product Name:       Other (please describe):       Name:      
3129		Overpayments ($) identified through data mining techniques:Data mining techniques used to detect Medicaid fraud, waste & abuse or inappropriate payments:		Algorithms Sampling Statistical analysis Models Artificial intelligence/fuzzy logic Other (please describe):      
3230		Overpayments ($) recovered through data mining techniques:Data mining analysis tools used to detect Medicaid fraud, waste & abuse or inappropriate payments:		Mainframe queries SAS SQL query Vendor toolset Name:       Commercial/off-the-shelf PC product Name:       Other, please describe:       Name:      
3331		Does the State typically extrapolate overpayments?Overpayments ($) identified as a result of data mining activities: Percent of cases opened from overpayments identified as a result of data mining activities:		Yes No            
3432		Total number of provider audits conducted: (Does the State staff vs. Contractor staff)typically extrapolate overpayments?		Desk Audits State staff:       Contractor staff:       Field Audits State staff:       Contractor staff:       Provider self-audits State staff:       Contractor staff:       Combination desk/field audits State staff:       Contractor staff:       Cost report audits State staff:       Contractor staff:       Total State staff:       Contractor staff:       Yes No
3533		Overpayments ($) identified throughTotal number of provider audits: conducted: (State staff vs. Contractor staff)		Desk Audits: State staff:       Field Audits: Contractor staff:       Provider self-audits:Field Audits State staff:       Combination desk/field audits: Contractor staff:       Cost report audits:Provider self-audits State staff:       Total: Contractor staff:       Combination desk/field audits State staff:       Contractor staff:       Cost report audits State staff:       Contractor staff:       Total State staff:       Contractor staff:      
3634		Overpayments ($) recovered throughidentified as a result of provider audits:		Desk Audits:       Field Audits:       Provider self-audits:       Combination desk/field audits:       Cost report audits:       Total:      
37[placeholder]		Mechanisms available to the public for reporting cases of suspected Medicaid fraud, waste, or abuse:Overpayments identified through Medicaid Integrity Contractor (MIC) activities:		Telephone hotline Website Email address Mailing address Other, please specify:      
3835		Total number of tips received from the public:Mechanisms available to the public for reporting cases of suspected Medicaid fraud, waste, or abuse:		Telephone hotline Website Email address Mailing address Other, please specify:      
3936		Total number of tips from the public that resulted in a recovery or referralreceived:		     
37		Total number of tips that resulted in a recovery or referral:		     
Investigation and Recovery
40	Does the State have written policies on determining when providers should be referred to the MFCU?		Yes No If yes, briefly describe:      
41Referrals to Law Enforcement
38		Number of casesDoes the State have written standard operating procedures (SOPs) for determining how and when providers should be referred to the MFCU: (per 42 CFR 355.13)?		Yes No If yes, briefly describe:      
4239		Does the State have formalized tracking systems that track the progress of Medicaid Integrity investigations?		Yes No If yes, briefly describe:      
4340		Does the State impose provider sanctions?Does the State have a process to track the number of referrals sent to the MFCU?		Yes No
4441		(If yesDoes the State have a process to Q43) Number of providerstrack the date that the State suspended payment: Number of providers referredreferrals were sent to the State licensing board:MFCU? Number of providers involuntarily dis-enrolled: Number of provider sanctions referred to OIG:		                        Yes No
Performance Measures1
4542		Does the State collect feedback from the MFCU to determine the number of accepted referrals?		Yes No
43		Estimated cost avoidance ($) of providers suspended, terminated, and withdrew voluntarily or involuntarily from the program:Number of referrals accepted by the MFCU:		     
4644		Percentage of individuals or entities applied for enrollment, but were denied:Number of referrals made to the MFCU:		     
47	Percentage of providers with identified overpayments:		     
48Provider Suspensions & Sanctions
45		Percentage of accepted referrals by MFCUsDoes the State impose provider payment suspensions due to inappropriate or fraudulent activities? (If yes to Q45) Number of providers that the State suspended payment: Number of payment suspensions:		Yes No            
4946		Total dollars recovered or cost-avoided through settlement or judgment. Does the State impose provider sanctions due to inappropriate or fraudulent activities? (If yes to Q46) Number of providers referred to the State licensing board: Number of providers involuntarily dis-enrolled: Number of provider sanctions referred to OIG:		Yes No                  
50	Measurement of administrative action against FFS and managed care providers (e.g., percentage of payment suspensions, referrals to licensing boards, involuntary dis-enrollment):		     
51Cost Avoidance
47		Cost avoidance dollars & dollars recovered related to system or policy changes:Does the State calculate the dollars cost avoided from terminating providers? (If yes to Q47) Describe methodology for calculating cost avoidance, including data sources used: Cost avoidance dollars from terminated providers:		Yes No            
5248		ROI Measurement for all Medicaid integrity activitiesDoes the State calculate the dollars cost avoided from providers that withdrew due to program integrity concerns: (If yes to Q48) Describe methodology for calculating cost avoidance, including data sources used: Cost avoidance dollars from terminated providers:		Yes No            

49	Does the State calculate cost avoidance dollars due to changes in payment systems? (If yes to Q49) Describe methodology for calculating cost avoidance, including data sources used: Cost avoidance dollars due to changes in payment systems: Does the State factor cost avoidance from payment system changes into its budget	Yes No             Yes No
50	Does the State measure cost avoidance dollars due to policy changes? (If yes to Q50) Describe methodology for calculating cost avoidance, including data sources used: Cost avoidance dollars due to changes in policies Does the State factor cost avoidance from policy changes into its budget?	Yes No             Yes No
51	List other administrative actions for which the State calculates cost avoidance:	     
Recoveries
52	Total recoveries ($) from data mining activities:	     
53	Total recoveries ($) from provider audits: Desk Audits: Field Audits: Provider self-audits: Combination desk/field audits: Cost report audits: Total:	                             
54	Total dollars recovered from ALL Medicaid Integrity activities (e.g., settlements/judgments, overpayments & other collections, MFCU investigations, other civil/criminal law enforcement, tips):	     
Technical Assistance Needs Assessment
55	Identify up to 3 areas that the State would like CMS to provide technical assistance and support:	                 

1 This preliminary set of proposed performance measures is based on analysis of the SPIA case study pilot data and feedback from the Medicaid Integrity Program Advisory Committee. CMS is in the process of developing a standardized set of data elements, definitions, and specifications for the SPIA performances measures.

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