VBP Program Integrity Workgroup Report and Recommendation

Public Comments
June 2017

Summary of General Comments

  1. Protect payer of last resort principles under VBP arrangements and change third party definitions in Social Service and Insurance law to compel cooperation for recoveries.
  2. Adopt a principled approach to VBP program integrity to include MCO oversight, MCO enhancements and coordination and validating payments for performance.
  3. Ensure timely and quality VBP data submissions, including sharing third party eligibility files and timely claims submission and processing, while prohibiting prior authorization and out of network denials.
  4. Leverage data for care management and member engagement.
  5. Monitor for increased utilization by patients who have transferred providers.
  6. Payment integrity requirements should not overburden smaller providers with limited capacity.
  7. Engage local governments in payment integrity risk management, payment model development and implementation.
  8. Recommendation #2 states that verification of accuracy of encounter data using other databases should be consistent with the Patient Confidentiality Workgroup recommendations, however that Workgroup has not opined on this topic.
  9. Health plans should undertake additional scrutiny when evaluating the accuracy of the VBP information where the patent has received an incentive payment from the health plan or provider in return for participating or completing any service.
  10. Extend the DSRIP IT Target Operating Model to the VBP program integrity concerns in a manner that protects Medicaid program integrity. Consult with MFCU and OMIG to consider whether the specific barrier that was eliminated pursuant to the 1115 waiver could be implemented for VBP without adversely affecting program integrity.
  11. Flexibility should not adversely affect Medicaid program integrity or decrease accountability or transparency, including the practical ability to measure the quality of patient care with accurate data.

Summary of Specific Encounter Intake System (EIS) and Data Comments

  1. SDOH should evaluate and enhance front– end data elements for EIS to focus on fields necessary for VBP implementation and program integrity, and reject and separately track incomplete submissions.
  2. Modify the Medicaid Data Warehouse to accommodate reporting of additional VBP fields.
  3. Maintain previously existing encounter data reporting requirements.
  4. Allocate dedicated program integrity staff at DOH and OMIG for encounter intake and audit.
  5. Create an indicator field identifying encounter records that are subject to VBP.
  6. Require encounter data to be submitted by the provider to the plan within 90 days from the date of service.
  7. Alignment of EIS data submission between Medicaid, Medicare and commercial must not preclude data reporting which is helpful for Medicaid program integrity.
  8. Create fields to ensure the linkage of any expected, obtained prospective or retrospective adjustment to payment received by a provider VBP contractor to the original date of service and claim.
  9. Create a VBP Adjustment Value field reflecting any changes made to the payment value.
  10. Plans should make sure that the ENCT_PMT_TYPE_CD is consistently populated, with additional edits for values of "E" to show the identity of the person and entity completing this field.
  11. Require reporting of the Actual Provider rendering the service wherever available, rather than substituting with a generic identifier (ex: MEDS OOS IDs).
  12. Add provider locator code as requirement so that appropriate monitoring of multiple sites of service can be performed.

Comment Compendia
April 2017

  1. Allow the flexibility for regulators and stakeholders to continue to change as needed, through Model Contract and policy rather than legislation.
  2. Align encounter data capture and data and payment integrity across Medicaid, Medicare and commercial.
  3. P4R measures should be included in the evaluation of existing patient access and experience measures.
  4. Implement specific oversight efforts to prevent inappropriate targeting of populations to achieve desired cost and outcome measures
  5. Using alternative and more holistic outcome measures that capture real value to patients rather than relying solely on claims/encounter data would align with VBP.
  6. Agree that DOH should adjust and/or add appropriate encounter data flags, edits, and fields.
  7. Other state agency data warehouses could be utilized as a secondary data source to test encounter data validity
  8. Sources to assist in effectively risk-adjusting rates include: RHIOs; Registries; CCDA extracts from CEHRT platforms; data sets submitted via GPRO, QRDA, or future methods of reporting; UAS and other CSV files containing relevant patient self-reported data
  9. SUD rate code encounter reporting needs to be improved for consistency and accuracy.