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Program Integrity: Fraud & AbuseGlendon SchusterSenior Vice President and Chief Technology Officer
Alliance for Health Reform Panel BriefingMarch 5, 2012
“It is the policy of Centene Corporation to conduct its business affairs in
accordance with the standards and rules of ethical business conduct and to abide by all applicable laws, both in
letter and spirit.
In this, there is no compromise.” - Michael F. Neidorff
Chairman, President and CEO
Program Integrity at Centene
Conventional Methods Preventive Approach
Supporting Program Integrity
Program Integrity – Conventional Methods
4
Centelligence™Through Centelligence™ we take our conventional methods
of Program Integrity to the next level.
Centene Preventive Approach
Demand for faster, more accurate payment
provides opportunities for engagement.
Health Information Technology
Provider Partnerships
Coordinated Care
Collaboration with our State Partners
• Health Information Technology (HIT)– Administrative Efficiency / Electronic Data Interchange (EDI)– Electronic Health Records, Member Health Records, Personal
Health Records, Health Information Exchange
• Provider Partnerships– Provider Support – Electronic Claim Submission– Joint Venture Partnerships
• Care Coordination– Member Connections– Co-Location Provider Offices and FQHC– Case Management
• State Partnerships – Participate with other MCOs and State
If you can run the company a bit more collaboratively, you get a better result, because you have more bandwidth and checking and balancing going on.
Larry Page, co-founder of Google
Centene Preventive Approach
Program Integrity - Results
EMPLOYEE EDUCATION
An employee reported concerns that a home health agency may
have been billing for services that the Foster Parent was providing
to their Foster Child. A record review validated the allegation
and identified a potential overpayment of $1.3 million.
The provider was reported to OIG for potential fraud.
We identified an Ophthalmologist consistently billing procedures on five consecutive days to enrollees that
lived in the same apartment complex.
Review of the records indicated significant concern and the case was referred to the MFCU.