Program Integrity

Meeting #1

Date: September 6, 2016 1:00 PM

Location: School of Public Health, 1 University Place, Rensselaer NY 12144


This was the first of three meetings for the Value Based Payment (VBP) Program Integrity (PI) workgroup. The overarching agenda for the PI Workgroup covers the following issues: (1) data quality, (2) policy design, and (3) risk management. Meeting #1 goals were workgroup member introduction, to provide a refresher on the New York State (NYS) VBP initiative, to formalize the role and charge of the workgroup, and to begin discussion on the first of three different policy issues–data quality.

The Agenda for this meeting included:

  1. Welcome and Introductions
  2. Workgroup Background
  3. VBP Refresher
  4. VBP Program Integrity Core Concepts
  5. Introduction to Data Quality and Workgroup Questions
    1. Policy Question A: Could the existing encounter reporting and enforcement process be leveraged more effectively in support of VBP?
    2. Policy Question B: Aside from encounter data, are there other sources of data, or potential enhancements to data sources, that could potentially serve to ensure that NYS is able to collect high quality submissions?

Key Discussion Points (reference the slide deck "PI Workgroup – Data Quality")

1) Workgroup Role, Scope & Charge

Jonathan Bick (DOH) along with the Co–chairs Robert Hussar and Jeffrey Gold facilitated the meeting. The workgroup members were given the opportunity to introduce themselves.

A key workgroup scoping decision included defining the charge of the workgroup to look at PI at an enterprise wide level. Rather than limiting the focus to a single actor in the Medicaid program, the workgroup agreed that it is charged with developing broad recommendations that will impact Medicaid providers, Medicaid Managed Care Organizations (MCOs), NYS and other elements the Medicaid delivery system.

The group determined that quality metrics and reporting are closely linked to the three VBP PI workgroup categories: data quality, policy design, and risk management. However, the workgroup acknowledged that the Clinical Advisory Groups (CAGs) are responsible for determining the appropriate quality measures; the charge of VBP PI workgroup is to ensure the integrity of the underlying systems and data that measure cost, quality and other relevant metrics.

2) Overview: VBP and PI Considerations

NYS´s transformation efforts were reviewed; DSRIP and VBP initiatives were highlighted. The three PI components were introduced and discussed among the workgroup members: (1) risk management, (2) policy design, and (3) data quality.

3) Policy Question A: Effective Leverage of Current Encounter Reporting and Enforcement Process

The workgroup began with representatives from enforcement agencies (MFCU, OMIG), program oversight agencies (OHIP, OMH, OASAS, etc.), and patient advocacy groups sharing lessons learned and concerns related to the current state of encounter and other relevant data and the necessary future state under VBP.

The workgroup agreed that the accuracy, timeliness and completeness of encounter data is of paramount importance. To ensure the accuracy, timeliness, and completeness of encounter data, the workgroup proposed developing a recommendation to include language in the Medicaid Managed Care Model Contract that would require the MCOs' Special Investigative Units (SIUs) place more scrutiny on the flow of claims and encounter data in cases where a provider and plan have entered into a VBP arrangement.

Finalization of these recommendations, or other data quality recommendations, has been deferred to meeting #2.

4) Policy Question B: Data Sources and Enhancements to Ensure High Quality Submission

The workgroup acknowledged that other data sources exist that could be used to test for the validity of encounter data submissions. These other sources include–but are not limited to–the Medicaid Managed Care Operating Report (MMCOR), Regional Health Information Organizations/Statewide Health Information Network for New York (RHIO/SHINY), and Electronic Health Records (EHRs).

The workgroup group noted that as NYS moves towards risk adjusting Managed Care premiums using encounter data, plan reported encounter data integrity should improve. The workgroup proposed developing a recommendation stating that the VBP risk adjustment process, coupled with the use of a secondary data source to test encounter data validity, could improve encounter data reporting. Specifically, it was recommended that NYS´s data audit protocol should test encounter data against third party and/or source data (i.e. EHR, claims data) for VBP quality and efficiency–related fields.

Finalization of this recommendation, or other data quality recommendations, has been deferred to meeting #2.

Materials distributed during the meeting:
Document Description
VBP PI Issue Brief This document details the high level policy questions related to program integrity as well as an overview of the current state of data quality, program design, and risk management efforts.
PI Workgroup – Data Quality A presentation deck of policy questions and options for data quality as it relates to VBP program integrity. Includes a background on VBP concepts and PI–specific VBP considerations.
Key Decisions

The WG made decisions on the following key points during meeting #1:

  • ✓ Deferral of the development of final recommendations for Data Quality rules to meeting #2. The workgroup members are to submit comments prior to the next meeting.
  • ✓ Explore as a possible recommendation for the VBP PI workgroup meeting #2 the role of SIUs in auditing encounter data.
  • ✓ Explore as a possible recommendation for the VBP PI workgroup meeting #2 stricter standards on encounter data fields that source relevant VBP quality and efficiency measures.
  • ✓ Explore as a possible recommendation for the VBP PI workgroup meeting #2 the use of risk adjusted premiums and secondary data sources to incentivize robust encounter data submission.
Action Items:
  • Determine the encounter data error rate for future meetings
  • Determine what SIU responsibilities are defined by the Model Contract
  • Develop further the possible recommendations coming out of the first workgroup meeting
  • Identify quality measures tied to each arrangement to asses potential PI integrity controls for second or third meeting

The next workgroup meeting will be held in Albany on October 14, 2016 and will include:

  1. A discussion of the WG members´ comments on Data Quality
  2. An introduction to the new WG topics including:
    1. Policy Design
    2. Safeguard Implementation