Pennsylvania DHS Announces Modernization of Program Integrity Efforts

Smarter use of technology and data analysis will reduce improper payments

Aug 05, 2015, 10:29 ET from Pennsylvania Department of Human Services

HARRISBURG, Pa., Aug. 5, 2015 /PRNewswire-USNewswire/ -- The Department of Human Services (DHS) today announced the implementation of innovative data analytics and technologies to modernize its handling of program integrity functions that block improper and fraudulent payments.   

"The Department makes billions of dollars in payments every year to providers, hospitals, insurance companies, and individual recipients," said Secretary Ted Dallas. "Introducing strategies that use data analytics and technology while eliminating cumbersome and error-prone manual processes is a smart way for the Department to become more efficient and accurate in the payments we make."   

Initial changes will include the following: 

  • Consolidation of the Office of Program Integrity and the Bureau of Program Integrity (BPI).  The Department will consolidate program integrity functions in one place by immediately combining these two offices.  The consolidated office will lead the drive towards greater accountability and efficiency in the Department's program integrity efforts.
  • Issuing a Request for Information (RFI) for program integrity data analysis of provider payments.  Approximately 98 percent of the payments made by the Department are to providers of services, not individuals.  The RFI will be released in the fall of 2015 for prospective data management contractors so that the Department can solicit ideas about where DHS can use technology, nationally-proven methods, and predictive data analysis to track provider payments and identify any patterns that require further investigation.  Currently, data mining is time-consuming and conducted manually by staff through review of claims data.
  • Implementation of Customer Portal for Third Party Liability (TPL).  The Department will implement a web portal for TPL customers by the first quarter of 2016.  While DHS collected $94 million last year in TPL – an increase of 17.5 percent from the previous year – the current manual process hampers the Department's ability to recover these funds in a timely and accurate fashion.  The web portal will modernize case processing to help ensure that Medicaid does not pay for services that should be covered by private insurance. 
  • Implementation of "identity proofing" of program recipients.  DHS issued a procurement request in June 2015 for a new data contractor to create a system that would electronically check additional personal information provided by applicants for benefits.  This "identity proofing" will automate the Department's process of validating the identity of the person who is applying for benefits.  The new system will go live in June 2016 and will verify the identity of adult individuals applying for and renewing benefits.  The new system will be integrated into the eligibility process for all adult applicants. 
  • Automating provider enrollment. The Department will implement an automated system for provider enrollment that will replace the current cumbersome and error-prone paper-based system.  This faster and more accurate system will help ensure that only qualified providers are allowed to do business with DHS.
  • Eliminate manual updating of milestone changes.  At present, the Department manually implements changes to consumer's cases when certain milestones–such as when a child reaches a certain age – trigger changes in benefits and eligibility.  In June 2015, the Department eliminated the manual process and implemented a faster and more accurate automated process that updates cases when milestones are reached.

"Data analytics is transforming the way that we work across the country," said Dallas. "These innovations can help the Department ensure that payments are made only for eligible services while at the same time making it easier for those eligible for benefits to interact with the Department."

The Department recovered and avoided costs of $582 million in improper payments in fiscal year 2014-15.  Of that amount, $431 million or 74 percent was related to improper payments made to providers.

MEDIA CONTACT: Kait Gillis, 717-425-7606


SOURCE Pennsylvania Department of Human Services