Health and Social Services take a new step in their efforts to reduce abusive payments
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Entrepreneur CGI recently won a contract with the Centers for Medicare and Medicaid Services. The task is to create an application programming interface, or API, gateway. This will be part of the agency’s efforts to reduce waste, fraud, and abuse in Medicare and Medicaid payments. With the way it should work, Federal Drive with Tom Temin turned to CGI’s vice president of health and social services, Brad Schoffstal.
Tom Temin: Mr. Schoffstal, nice to have you.
Brad Schoffstal: Thanks, Tom, nice to be here.
Tom Temin: And what exactly is CMS asking you to do here? API Gateway looks like a big bunch of programming.
Brad Schoffstal: Law. Well, CMS therefore has the responsibility to monitor health insurance providers. So there is a whole series of processes that a provider must go through in order to be certified to actually provide health insurance and billing services. And therefore PECOS is the supplier registration system that has this data. And then there are additional systems than CMS that have additional data. And all of that data is needed to really make sure that the suppliers are good suppliers and that they are doing the right thing. So, since the data is in several different systems, CMS wanted to have an API gateway to bring all this data together. So, in one place, you can have a 360 degree view of a health insurance provider that is available for a variety of stakeholders and purposes.
Tom Temin: The data would therefore include not only who they are as self-identified health care providers across the country, but also the payments made to them, the cases they submit for reimbursement, etc.
Brad Schoffstal: Law. The records they submit, they must submit their license to practice and other information, all of their facilities where they practice, in which states they practice, each license by state. In addition, if it is a doctor who has different specialties, he must have licenses for each. So everything that is subject to Medicare, and everything is controlled by PECOS and the systems associated with the Center for Program Integrity, CPI, which is part of CMS. And that information then feeds into the actual claims systems that pay the claims. And so, the claims system uses this data to verify that yes, that provider is in fact an approved Medicare provider.
Tom Temin: OK. So how will this API apply to all of these different datasets, how will it help detect fraud and reduce inappropriate payments? Because I guess CMS is the biggest contributor to total federal inappropriate payments every year.
Brad Schoffstal: So, in various ways, most of the data at this point is sent from Pecos to other systems as snippets, while this gateway allows real-time data sharing with those other systems. It is therefore available via the API. So she said, so a programming interface or a resting interface to get this data compared to sending a file, then extract from that file, what you need to verify this provider. This therefore improves access to data, or data in real time. So it’s a system-to-system type setup, but there is also a portal. So users, let’s say it is the MA or the IG or the FBI, regardless of the organization involved in the fight against fraud, can use the portal on the internal CMS network, there are ways for them to enter it, means approved, so that they can actually pull that data for that provider. And then go through their processes to check for fraud.
Tom Temin: After tracking some of the big fraud cases that have happened, in many cases CMS pays people who are actually qualified, they are real doctors and nurses and so on real providers, but they just make a big deal. number of identical complaint types. , that sort of thing continues. That is, they are real but they do not act in a legal manner. Will that allow people like the FBI, the Office of Program Integrity, or the Inspector General to spot them sooner than they currently can?
Brad Schoffstal: Yes, that’s the idea, it’s to have the data available on the supplier side, a 360 view of the supplier available in real time. So this can be compared, again, to the use case you mentioned, so that this data is available to match with other providers, beneficiaries, other billers or service recipients to check if it s. This is an ongoing program. So it requires a lot of research. And it’s not just a simple query that finds something like that, is it.
Tom Temin: Sure. We speak with Brad Schoffstal, he is vice-president for health and social services at CGI. And what is required of CGI to do that, to create an API and a portal? It looks like two components of the total system here.
Brad Schoffstal: Oh yes. Well, we’ve put together a whole software stack with CMS that pulls this data from the different systems of a service, sort of an activation. So if you think about it, it’s like a virtualized data environment. So we have all these real databases on CMS and we combine them in a virtual way so that it looks like one big database, but no data is actually copied anywhere. It’s really just put in memory, and it looks like a bigger database and provides that 360 ° view. So there is a lot of software that goes into this for sure.
Tom Temin: And is it all in a cloud somewhere?
Brad Schoffstal: Well, it’s a combination. It’s in the AWS cloud, and also on CMS data centers. So it’s a combination. And in fact, the data entering this API Gateway comes from multiple data centers. So if you think of someone who has to access different systems in different data centers, have different connections one after another, and put the data together manually, well, that does it for them in an automated way.
Tom Temin: Understand it and give us an idea of ââthe range of data types involved here. Because when you talk about different data centers and multiple applications, it might really look like the barroom type picture on Mars of incoming data types.
Brad Schoffstal: Data types are all structured data, for the most part. There are images in that they actually take license images and verify the licenses. CPI has a lot of different processes for eradicating fraud. So they do background checks on the providers, they do site visits for the actual sites – so they check that the provider says they actually have facilities in a certain location, they verify that they are there and that they can. provide the services that the provider says they offer. There are therefore both systematic and real controls on the ground.
Tom Temin: And for CGI, is the measure of their success just that the portal is up and running or do they have some, I don’t know, increased detection of fraud in the performance framework here?
Brad Schoffstal: Yes. This is therefore what is defined by the stakeholders. So the stakeholders who use the system, they are the ones who, through their use cases, define how well the system works, how it fulfills the mandates, if you will, of the objectives actually advanced by CMS. So it’s really up to them. This system is currently being put into production, it will be operational by the end of the year. So we’re doing a lot of testing now. And the users who go through this process to say is this system really delivering what we need. And so far we are getting very good feedback. And the user community is actually very anxious to have this in production to help them with the goal of eradicating Medicare fraud.
Tom Temin: Just to say you develop this, CGI develop this in an agile way so that you can test the functionality among users and adjust it before they commit to finished code at runtime?
Brad Schoffstal: Oh, yeah, absolutely. Everything is safe and agile. So we are product owners and they participate several times a week in standing meetings and all the other activities that go into the agile process.
Tom Temin: Will it be something that you deliver and then you’re done? Or will you mine it for them and continue to develop over time?
Brad Schoffstal: Yes, we are in the first phase, there are several phases planned after this first phase. So initially they start with three or four systems, something like that, I think it’s going to be three when they actually get online. But then they’re looking to add five more systems every year, as well as multiple users, 20-30 new stakeholder bodies every year as well. The idea is therefore that it could be available through the CMS. Also available even to Medicaid stakeholders in different states.
Tom Temin: I was going to say that most of this money is spent by the states, so they would have an overall interest as well, right?
Brad Schoffstal: Oh yes. CMS is very convinced that they want to provide services for Medicare and Medicaid, and to have transparency on both sides so that there is no situation where – someone falling through the cracks is terrible . But also by making sure that someone doesn’t get double the benefits they really should be receiving.
Tom Temin: And do you think that the architecture and maybe some of the code itself of the system you are developing is reusable by other agencies that have all these different programs that are aimed at stakeholders, farmers or whatever? or else?
Brad Schoffstal: Yeah, well, the software we use is available either open source or commercially. So a stack could certainly be exploited by anyone who wanted to go this route. As for sharing the designs put together by CMS, I can’t really talk about that at this point.
Tom Temin: OK. Brad Schoffstal is Vice President of Health and Social Services at CGI. Thank you very much for joining me.
Brad Schoffstal: Sure. Thanks, Tom. I liked that.