Create a Shared Service Provider Screening Program for Medicaid
The Centers for Medicare & Medicaid Services (CMS), is announcing the launch of the “CMS Provider Screening Innovator Challenge.” This Challenge is sponsored by CMS and is presented as part of the Partnership for Program Integrity Innovation program, and will be administered by the National Aeronautic and Space Administration’s (NASA) Federal Center of Excellence for Collaborative Innovation. This Challenge addresses our goals of improving our abilities to streamline operations, screen providers, and reduce fraud and abuse. Specifically, the challenge is an innovation competition to develop a multi-State, multi-program provider screening software application which would be capable of risk scoring, credentialing validation, identity authentication, and sanction checks, while lowering burden on providers and reducing administrative and infrastructure expenses for States and Federal programs. More information pertaining to the Medicaid and CHIP programs can be found at www.medicaid.gov.
DATES: Important dates concerning the Challenge include the following:
Challenge Competition Begin: 6:00 pm, e.d.t., May 30, 2012.
Challenge Competition End: To be determined, but expected to be completed by October/November 2012 timeframe.
Subject of Challenge Competition:
Entrants are asked to develop artifacts and components of software applications that can be integrated into an open source solution that can deliver a reliable, scalable, and cost-effective provider-screening capability for multiple States (or for the nation).
We expect the winning entry to exhibit the following characteristics:
1. Reduced processing and transaction time for submitting and receiving queries to authoritative data sources regarding provider credentials and sanctions.
2. Reductions in time needed by providers to submit information and resolve discrepancies.
3. Administrative/infrastructure savings from a multi-tenant provider screening solution.
4. Improved availability of key provider data relevant for program participation and oversight.
5. Improved timeliness and accuracy in provider participation, oversight, and enrollment decisions.
6. Improved ability to implement sections 1902(a)(39) and 1902(a)(77) of the Social Security Act, as amended by the Patient Protection and Affordable Care Act (P.L. 111-148 and 111-152) subsections 6401(b) and (c) (Provider Screening and Other Enrollment Requirements Under Medicare, Medicaid, and CHIP), and section 6501 (Termination of Provider Participation Under Medicaid if Terminated by Medicare or Other State Plan).
- Assist in better driving alignment of the Medicaid Information Technology Architecture (MITA) 3.0 framework to the Information and Technology Architecture levels. More information pertaining to MITA can be found at the following Web site: www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Data-and-Systems/Medicaid-Information-Technology-Architecture-MITA.html .
General Eligibility Rules for Participating in the Competition:
To be eligible to win a prize under this Challenge, an individual or entity must comply with all the requirements under this section.
An individual or entity shall not be deemed ineligible solely because the individual or entity used Federal facilities or consulted with Federal employees during a competition if such facilities and employees are made available to all individuals and entities participating in the competition on an equitable basis.
A Federal entity or Federal employee acting within the scope of his or her employment is not eligible to participate. A Federal employee seeking to participate in this competition outside the scope of his/her employment should consult his/her ethics official prior to developing the submission. Employees of CMS, the Challenge judges, and employees of any other company or individual involved with the design, production, execution, or distribution of the Challenge, along with such employees’ or judges’ immediate families (spouse, parents and step-parents, siblings and step-siblings, and children and step-children) and household members (people who share the same residence at least three (3) months out of the year) are not eligible to participate.
Regarding Registration Process for Participants, interested persons should read the Official Rules and register at the Center of Excellence for Collaborative Innovation Challenge portal: http://community.topcoder.com/coeci/. Registration is free and can be completed at any time before an entry is submitted in response to a particular competition.
Amount of the Prize:
Based on our current assumptions, we estimate that the total prize amount for the competitions conducted as part of this Challenge will fall between $500,000 and $600,000.
Basis Upon Which Winner Will Be Selected:
Challenge competition entries will be judged by an expert panel composed of CMS program staff. Judges shall be named after commencement of the Challenge. Competitions will be judged based upon both subjective and objective criteria. Should the highest-scoring submitted solution be missing requirements or otherwise need modification, it will enter a remediation/fix phase. Projects are posted and administered through a personalized, web-based administration tool. All projects progress, with some variance, through a sequence of phases from Registration to Submission to Screening to Review to Final Fixes. Submissions will be screened to ensure they meet minimum requirements for the project and do not include forbidden material. Competition submissions with subjectively-evaluated components (for example, graphical design, workflow, GUI layout, etc.) are anonymized and evaluated by the Judges. Submissions with objectively-scored components, such as projects (for example, architecture, development, etc.) are scored by the Judges by their fidelity to exact, enumerated requirements.
Overall, the solution must, at a minimum, meet the following criteria:
1. Capability to Conduct Identity Verification.
a. Capability to link individuals to their organizations and vice versa.
b. Capability to match on multiple variations of an individual’s or organization’s name to ensure that the correct entity is verified.
c. Ability to apply a range of screening rules to cross check data elements within the enrollment application.
d. Ability to apply a range of screening rules to cross check data elements against authoritative external sources for consistency.
e. Capability to establish and employ a graded screening methodology that escalates the intensity of screening for providers that are flagged as higher risk (that is, Report Card Methodology).
2. Capability to Build Provider Profiles
a. Capability to retain screening and enrollment information and results, and compare against past and future screening results.
b. Capability to create a watch list to ensure that providers that are suspected or known to be fraudulent are flagged at the time of screening.
c. Capability to track re-enrollment attempts to ensure that slight changes to provider information are not considered a new enrollment.
d. Capability to revalidate periodically to ensure that changes in provider profiles are updated on a regular basis.
e. Capability to leverage public Web sites to conduct link analysis through which provider associations could be explored, and alerts posted on similar Web sites could be considered.
f. Capability to capture critical attributes
● Collection of application fees status.
● Exception waiver approved status.
● Incorporating enhanced screening data, including the results of site visits, criminal background checks, and finger printing.
● Capturing licensing information, financial data, and any other data attributes which could impact a risk lever.
● Other critical attributes.
g. Capability to achieve real time screening, scoring, and system outputs (queries/reports).
3. Capability to Evaluate and Maintain the Integrity of the Results.
a. Capability to persist data sources scores to determine the most reliable source for each data element.
b. Capability to evaluate data sources for reliability and accuracy.
c. Capability to create a learning system to ensure that observed negative trends factor back into screening rules so as to flag suspicious enrollments early in the screening process, ensuring the ability to detect and reduce/eliminate the incidence of false positives.
d. Capability to create system outputs to assign reasons/explanations to each code or score used.
e. Capability to build processes to allow for appropriate interpretation and action on screening and scoring results.
f. Capability to ensure that each rule is tested and its impact is evaluated prior to implementing.
4. Improves Efficiency.
a. Capability to allow searches to find specific provider information with minimal search attempts.
b. Capability to identify applicants, including individual providers and owners of institutional providers.
c. Capability to verify identity and prior history of problems with Medicaid/CHIP or Medicare programs.
d. Capability to identify and schedule revalidation process.
5. Meets Architectural Guidelines.
a. Adheres to the Architectural Guidance and meets the seven conditions and standards detailed in the Guidance for Exchange and Medicaid IT Systems, Version 2.0, located at: http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Data-and-Systems/Downloads/exchangemedicaiditguidance.pdf .
b. Integrates into the MITA Framework – Is MITA Compliant. Information regarding MITA can be found at: http://www.cms.gov/MedicaidInfoTechArch/.
6. Accurate, Cost Effective, and Timely.
a. Turnaround time for performing automated checks typical for a web-based system.
b. Comprehensive verification of all data fields for all providers enrolled.
c. Efficiency of the Screening Solution in terms of cost and schedule to actually implement: Potential extra costs (for example, licenses, etc.) are documented.
d. Effectiveness of the risk-screening model in detecting fraud based issues.
e. Technical soundness of risk-scoring in flagging potential fraudulent patterns and tendencies.
CMS is one of the principal agencies dedicated to protecting the health of citizens by making our world healthier, safer, and better for all Americans. For more information, see www.cms.gov.
The Challenge will Launch at 6pm EDT May 30th
If you would like to register to participate in the challenges, please click here (this will open a new window).
Please check back for more detail on the challenge!