Case Studies

“The only source of knowledge is experience” -Abert Einstein

CMS Unified Case Management

Client: Centers for Medicare & Medicaid Services (CMS)

Challenge

HHS awarded the first contract to IBM, then TISTA, as a first-of-its-kind effort to create, develop and deploy a single tool to capture the entirety of work needed to perform fraud waste and abuse (FWA) investigations, audits and medical record reviews, using a single case management tool. Advize was selected by both IBM and TISTA as a subcontractor to join this effort in supporting requirements teams, business analysts, scrum masters, user experience and executive management teams in assisting with the integration of medical record review and law enforcement to supply real-life examples and requirements.

Solution

Advize supplied prime contractors with resources as needed which ranged from law enforcement subject matter experts (SMEs) to clinical experts with experience in coding and billing to support Human Centered Design (HCD) and Agile Scrum methodologies.  We supplied these resources to direct, suggest, advise and guide the prime contractor team for requirements gathering and development.

Outcome

We worked closely with the CMS to build requirements that allow UCM to integrate more easily with investigative tracking, case documentation, workflows, and medical record reviews. By assisting the prime vendors implement solutions serving real life users and understand real use cases as well as industry best practices, we were able to help deliver better deployments and increased usage of the tool and better communication between CMS, the UPICs and prime contractors.

DRG Audit for Medicaid MCO

Client: Undisclosed

Challenge

A large urban Medicaid Managed Care Organization (MCO) covering in excess of 2 million lives engaged Advize to review a number of in-patient records for which payments were made by that MCO. Advize’s clinical DRG audit staff identified an error rate of approximately 75% percent, reflecting over-coded, and under documented, services rendered to patients. Potential overpayments were in the hundreds of thousands of dollars if the MCO chose to seek recoupment.

Solution

Self-Disclosure Protocol work with our law enforcement partners identifying the submission of claims to Medicare in excess of $1 million. As a result of our retired OIG Special Agents working with the provider and the law firm in conducting an internal investigation, we were able to limit the damages, reduce criminal exposure and identify the loss amount for this matter with pinpoint accuracy.

Outcome

We have provided expert reporting and testimony for multiple payer clients, including PBMs and commercial plans. Our expert reporting was relied upon in arbitrations and federal litigation, where nearly $100 million in potentially false payments were made.

IT Security for Behavioral Health

Client: Undisclosed

Challenge

A regional non-profit behavioral health care organization that delivers a comprehensive and integrated system of care for adults, children and families who are struggling with mental health, substance use, and/or domestic violence required an IT Security Assessment.  Leadership requested that the assessment include current and future operating environment, particularly around HIPAA Compliance, so that Leadership & Staff are aware of any risks, understand their impact and most importantly, are armed with commensurate information to support effective decision making in the event risk mitigation recommendations are made.

Solution

Advize provided the client with an evaluation of its current IT related processes, infrastructure, security vulnerabilities, disaster recovery procedures, and operational service orientation compared to sound industry practices.  In particular, Advize’s analysis focused on the IT group and the procedures and policies it has employed to maintain and support its end users’ EHR application and supporting infrastructure.  Advize’s engagement was designed to assess various areas within IT, including an analysis of:

  • Technical and Physical Security
  • Technology Assets
  • Physical Assets
  • IT Security Policies, Plans, Procedures
  • Staff Information Technology Knowledge

Outcome

Several significant findings were associated with this project.

  • IT Change Control policies were reviewed and enhanced, procedures were reviewed for completeness and accuracy and recommendations were made
  • Advize performed a structured diagnostic analysis that focused on:
    • Management of IT operations via Policy and Procedures
    • Computer Operations and Disaster Recovery with respect to web and support systems; and
    • Web Application, Network, and Infrastructure Security with respect to key systems.
  • Advize’s findings were documented in a report and presented to leadership in a formal meeting. Recommendations around security mitigation based upon any risks/issues identified were included as well as intrusion and penetration testing log and assessment information.
  • Advize’s recommendations lead to a streamlining of the IT security workforce and a savings of 10% labor which was added to the security strengthening initiatives.

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