Medicaid State Program Integrity Assessment (SPIA) CMS-10244

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	Organizational structure for Medicaid Integrity activities within the State:	Distinct Program Integrity Model Inspector General (IG) Model Hybrid Model
8	Activities that the State includes under the scope of Medicaid Integrity:	Audits Investigations SURS/Data Mining Provider Enrollment Provider Education/Communications Managed care oversight Other, please specify:      
9	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 ($) Audits: Investigations: SURS/Data Mining: Provider Enrollment: Provider Education/Communications: Managed care oversight: Other: Total:	                                               
Planning
Staffing
11	Total number of FTEs (filled and vacant) for all functions considered to be Medicaid Integrity:	Audits: Filled:       Vacant:       Investigation: Filled:       Vacant:       SURS/Data Mining: Filled:       Vacant:       Provider Enrollment Filled:       Vacant:       Provider Education/Communications: Filled:       Vacant:       Other:       Filled:       Vacant:      
IT Resources
12	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:      
Strategic Planning
13	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:      
14	(If yes to Q13) 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
15	Total number of participating Medicaid providers:	     
16	Number of providers applied for enrollment in Medicaid during FFY:	     
17	Number of providers denied enrollment in Medicaid during FFY:	     
18	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):      
19	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      
20	Does the State have written policies giving direction to providers and managed care organizations 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
21	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
22	Does the State include TPL as part of its Medicaid Integrity activities?	Yes No
23	Does the State include TPL recoveries as part of its Medicaid Integrity return-on-investment?	Yes No
Prior Authorization
24	Does the State include prior authorization as part of its Medicaid Integrity activities?	Yes No
25	Does the State include prior authorization cost avoidance as part of its Medicaid Integrity return-on-investment?	Yes No
Provider Education
26	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 State Medicaid Agency administrators or staff to stakeholder organizations about Medicaid fraud, waste, and abuse. News releases from State 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
27	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 to disseminate lessons learned from the case? Yes No
28	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:      
29	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):      
30	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:      
31	Overpayments ($) identified as a result of data mining activities: Percent of cases opened from overpayments identified as a result of data mining activities:	           
32	Does the State typically extrapolate overpayments?	Yes No
33	Total number of provider audits conducted: (State staff vs. Contractor staff)	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:      
34	Overpayments ($) identified as a result of provider audits:	Desk Audits:       Field Audits:       Provider self-audits:       Combination desk/field audits:       Cost report audits:       Total:      
[placeholder]	Overpayments identified through Medicaid Integrity Contractor (MIC) activities:	     
35	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:      
36	Total number of tips received:	     
37	Total number of tips that resulted in a recovery or referral:	     
Investigation and Recovery
Referrals to Law Enforcement
38	Does 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:      
39	Does the State have tracking systems that track the progress of Medicaid Integrity investigations?	Yes No
40	Does the State have a process to track the number of referrals sent to the MFCU?	Yes No
41	Does the State have a process to track the date that referrals were sent to the MFCU?	Yes No
42	Does the State collect feedback from the MFCU to determine the number of accepted referrals?	Yes No
43	Number of referrals accepted by the MFCU:	     
44	Number of referrals made to the MFCU:	     
Provider Suspensions & Sanctions
45	Does 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            
46	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                  
Cost Avoidance
47	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            
48	Does 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:	                 

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