© 2011 IBM Corporation 1
FAMS Visualization Report Card
Report Card’s show a providers behavior across all features in a model
– Shows values, ranking, and peer group comparison scoring for all features, groups and composite
© 2011 IBM Corporation 2
Claims Reports
General procedure and diagnosis utilization reporting
Procedure, diagnosis and claim detail breakdowns by– Provider– Recipient– Provider and recipient
Recipient Drift Report
Procedure Code combination reporting
Claim detail reporting
Claim detail cross referencing to models
© 2011 IBM Corporation 3
Models available to MCO’s for profile creation
Outpatient Behavioral Health Therapist Model– Outpatient Therapist Profile– Outpatient Therapist Group Profile
CABHA Model– CISA Profile– CABHA Profile
Outpatient Behavioral Health Physicians Model– Outpatient Physician Profile– Outpatient Physician Group Profile
Residential Child Care Center Model– Residential Child Care Center Profile
Psychiatric Residential Treatment Facility Model– Psychiatric Residential Treatment Facility Profile
© 2011 IBM Corporation 4
Maintaining and upgrading models
FAMS Application Models
Data Analytics Team(DAT)
MCO Analyst
MCO ModelCommittee
AnalysisProfiles
•MCO’s will all use the same models
•Models are maintained by Program Integrity
•Changes to the model and creation of profiles are managed by the Data Analytics Team
© 2011 IBM Corporation 5
Claims Data Process
Recipient + Provider = Visit
HP /MMIS/DRIVE
Recipients Provider EncounterData
Claim for visit
MCO SpecialInvestigations
Unit
Monthly FAMS
Data Load
MCO ClaimProcessing
FAMS datamart
ModelsAnalysis Profiles
Program IntegrityData Analytics
Team
© 2011 IBM Corporation 6
Data quality
FAMS depends on encounter claims submitted– All claims need to be submitted– Claims should not be duplicated
Since FAMS is retrospective…– There must be historical claims to analyze– Claims must be submitted on a timely basis
Garbage in Garbage out– Claims must be accurate and contain the appropriate information in the fields– More information the better
© 2011 IBM Corporation 7
Separation of Data
DMA IT Access
Data Analytics
Team Access
Value Sets by MCO
MCO Access
FAMS Data StorageIncludes MCO Claims
NCID
FAMS Models
AnalysisProfilesby MCO
MCOMCO
MCO
MCO
MCO
MCO Claims System
MCO Reporting System
HP MMIS/DRIVE
•Each MCO will only have access to their own data
•This will be achieved through role based security at login
•MCO’s will be allowed 4 users per organization (expected)
© 2011 IBM Corporation 8
Security requirements for access
Security requirement definitions are currently in process
Items being discussed:– What hardware will be needed for access?– How will logins be configured?– How will access be maintained?
Once they are defined security settings will be communicated to the MCO’s
© 2011 IBM Corporation 9
Project Timeline
Assign models for MCO’s to use
Establish Beta tester
Complete mapping and test loading of encounter claims
Create test profiles
Hold MCO training
Implement FAMS for MCO’s ready to go live– January 1, 2013– For those MCO’s not yet live, a rolling implementation will occur once encounter claims
history is established
Hold follow up training
© 2011 IBM Corporation 10
Training
Identification Methods
Investigation process
Common Schemes
Basic “How to” in FAMS
Helpful reports
Business examples
How to create “Allegation
packages”
© 2011 IBM Corporation 11
Ongoing Support
FAMS Team– Thomas Nisbet IBM Consultant– Marianne Hungate, IBM Consultant– Steve Sharp, IBM Project Manager
Support line
Allegation Package creation
Ongoing scheduled meetings and communications
© 2011 IBM Corporation 12
Questions?