Figure 7: Program Integrity Management Summary The primary factors affecting maturity ratings across the Program Integrity Management business area include the following: Data retrieval is automated; data analysis is a mix of manual and automated steps Case identification is not standardized and comes from multiple sources Internal referrals are paper based and communicated manually Impact of Managed Care on Program Integrity Management The switch to a dual-model with the bulk of the members enrolled in a MCO will have the following impacts on the Program Integrity Management business area. Fraud prevention becomes a shared responsibility with the MCOs Case identification and case management activities reduce due to the drop in FFS claims. Business Capabilities Matrix This section articulates the maturity level of the individual business processes within the Program Integrity Management business area for the Medicaid Enterprise. While all MITA Framework 2.01 capabilities will be addressed for each target maturity level, the table below focuses on the key rationale to support the maturity level determinations. Table : Program Integrity Process Summaries As Is mita business As Is Process Description Program Integrity – maturity process Management level PI01 Identify 1 Data and policy analysis is a mix of manual and automated Candidate steps. The process is duplicated in multiple parts of the organization Case tracking is manual. Case identification is not standardized. Internal referrals are paper based. PI02 Manage Case 1 Process is a mix of manual and automated steps. The process is duplicated in multiple parts of the organization Data is evaluated manually. Case tracking is manual. Internal referrals are communicated manually.
Figure 7: Program Integrity Management Summary The primary factors affecting maturity ratings across the Program Integrity Management business area include the following: Data retrieval is automated; data analysis is a mix of manual and automated steps Case identification is not standardized and comes from multiple sources Internal referrals are paper based and communicated manually Impact of Managed Care on Program Integrity Management The switch to a dual-model with the bulk of the members enrolled in a MCO will have the following impacts on the Program Integrity Management business area. Fraud prevention becomes a shared responsibility with the MCOs Case identification and case management activities reduce due to the drop in FFS claims. Business Capabilities Matrix This section articulates the maturity level of the individual business processes within the Program Integrity Management business area for the Medicaid Enterprise. While all MITA Framework 2.01 capabilities will be addressed for each target maturity level, the table below focuses on the key rationale to support the maturity level determinations. Table : Program Integrity Process Summaries mita business process As Is maturity level As Is Process Description – Program Integrity Management PI01 Identify Candidate 1 Data and policy analysis is a mix of manual and automated steps. The process is duplicated in multiple parts of the organization Case tracking is manual. Case identification is not standardized. Internal referrals are paper based. PI02 Manage Case 1 Process is a mix of manual and automated steps. The process is duplicated in multiple parts of the organization Data is evaluated manually. Case tracking is manual. Internal referrals are communicated manually.