Along with approximately one-thousand state and federal Program Integrity professionals and experts, PCG’s Health team sponsored, attended and presented at the 2021 National Association of Medicaid Program Integrity (NAMPI) virtual conference, which took place from Monday September 13th through Wednesday September 15th, 2021.
The conference kicked off with a keynote from Dan Cnossen, a U.S. Navy Seal and 2-time Paralympian. His story of focus and overcoming adversity, as well as his message of incremental thinking in overwhelming and critical moments, was a great parallel to the challenges that state Medicaid agencies have been facing against the backdrop of the pandemic and increasing fraud and abuse schemes. The conference also featured numerous presentations regarding new and evolving fraud, waste, and abuse (FWA) schemes, as well as approaches to identifying and eliminating them. Many of these discussions revolved around the COVID-19 pandemic, covering timely topics such as the emergence of excessive testing and vaccinations as a FWA scheme; the need to improve provider exclusion data processes to account for rising provider need and migration; and growing telehealth spends—including questions regarding what services should and should not be provided this way. Other insightful presentations touched on topics like the rising utilization of AI/Machine learning and social media data to identify outliers and fraud schemes, as well as the pressure that states face to control pharmacy benefits manager (PBM) overpayments and abuse.
PCG Health team members presented in two breakout sessions with vendor partners on the first day of the conference:
Along with our partner HealthPlan Data Solutions (HDS), PCG team members gave a presentation entitled “Risks Around Pharmacy Integrity.” This presentation discussed on the need for comprehensive, real-time PBM oversight in light of recent findings and legal settlements in several states, and focused specifically on the need for a solution that goes beyond some of the more common regulatory PBM issues, such as “spread pricing”.
The PCG team also presented in partner Lexis Nexis’ session, “Going Beyond Claims: Integrating Non-Traditional Data and Methods to Advance State Medicaid Program Integrity,” which outlined a three-pronged approach for optimizing cost avoidance and recovery. This approach entails utilizing datasets beyond claims, as well as applying advanced analytical tools such as machine learning, in combination with Program Integrity staff augmentation to maximize FWA results. Presenters shared benefits of the PCG/Lexis Nexis Program Integrity Solution, which brings together all three of these aspects in attempt to optimize states’ return on investment—particularly those with limited organizational staff resources.
If you are interested in learning more about the topics covered at this year’s NAMPI conference, or about PCG’s Program Integrity or Pharmacy Benefit Manager Oversight services, please feel free to reach out to Chris Richter at crichter@pcgus.com.
