Welcome to the Medicaid Provider Enrollment Screening Portal Project

Contents:

1. How the project was built
2. Features and Functionality
3. Licensing

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SECTION 1: How the project was built

The NASA Center of Excellence for Collaborative Innovation (CoECI) through an Interagency Agreement with the Centers for Medicare and Medicaid Services (CMS) administered a crowd-sourced application development challenge for the Medicare and Medicaid Services, Center for Medicaid and CHIP Services (CMCS). The challenge was to build a multi-state, multi-program provider screening application capable of risk scoring, credentialing validation, identify authentication, and sanction checks, that lowered the burden on providers and reduced administrative and infrastructure expenses for states and federal programs.

The application was built using NASA's contract with Harvard Business School in association with the Institute of Quantitative Social Sciences and their subcontract with TopCoder. The Application Development Challenge was sponsored by CMS as part of the Partnership for Program Integrity Innovation program with the specific intent of developing an application to improve capabilities for streamlining operations and screening providers to reduce fraud and abuse.

The result and code contained herein is the result of that challenge. The challenge was comprised of an omnibus of 120 contests launched between June 2012 and April 2013, to cover all phases of the software devleopment life cycle. More information on the challenge can be found here: http://www.topcoder.com/cms/medicaid-enrollment-portal/

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SECTION 2: Features and Functionality

1. Capability to Conduct Identity Verification

• Capability to link individuals to their organizations and vice versa
• Capability to match on multiple variations of an individual's or organization's name to ensure that the correct entity is verified
• Applies a range of screening rules to cross check data elements within the enrollment application
• Applies a range of screening rules to cross check data elements against authoritative external sources for consistency
• Capability to establish and employ a graded screening methodology that escalates the intensity of screening for providers that are flagged as higher risk (i.e., Report Card Methodology)

2. Capability to Build Provider Profiles

• Capability to retain screening and enrollment information and results and compare against past and future screening results.
• Capability to create a watch list to ensure that providers that are suspected or known to be fraudulent are flagged at the time of screening*
• Capability to track re-enrollment attempts to ensure that slight changes to provider information is not considered a new enrollment
• Capability to re-screen periodically to ensure that changes in provider profiles are updated on a regular basis
• Capability to leverage public websites to conduct link analysis through which provider associations could be explored and alerts posted on similar websites could be considered
• Captures critical attributes. ** Collection of application fees status * ** Exception waiver approved status ** Incorporates enhanced screening data including the results of site visits, criminal background checks and finger printing ** Captures licensing information, financial data and any other data attributes which could impact a risk lever ** Other critical attributes
• Capability to achieve real time screening, scoring and system outputs (queries/reports)

3. Capability to Evaluate and Maintain the Integrity of the Results

• Capability to persist data sources scores to determine the most reliable source for each data element
• Capability to evaluate data sources for reliability and accuracy
• Capability to create a learning system to ensure that observed negative trends factor back into screening rules so as to flag suspicious enrollments early in the screening process, ensuring the ability to detect and reduce/eliminate the incidence of false positives**
• Capability to create system outputs to assign reasons/explanations to each code or score used
• Capability to build processes to allow for appropriate interpretation and action on screening and scoring results
• Capability to ensure that each rule is tested and its impact is evaluated prior to implementing

4. Improves Efficiency

• Allows search capability to find specific provider information with minimal search attempts
• Capability to identify applicants including individual providers and owners of institutional providers
• Capability to verify identity and prior history of problems with Medicaid/CHIP or Medicare programs
• Identifies and schedules revalidation process

5. Meets Architectural Guidelines

• Adheres to the Architectural Guidance and meets the seven conditions and standards detailed in the Guidance for Exchange and Medicaid IT Systems, Version 2.0, located at: http://cciio.cms.gov/resources/files/exchange_medicaid_it_guidance_05312011.pdf

6. Integrates Into the MITA Framework / Is MITA Compliant

• Information regarding MITA can be found at: http://www.cms.gov/MedicaidInfoTechArch/

7. Accurate, Cost Effective, and Timely

• Turnaround time for performing automated checks typical for a web based system

• Comprehensive verification of all data fields for all providers enrolled

• Efficiency of the Screening Solution in terms of cost and schedule to actually implement

• Potential extra costs (e.g. licenses, etc) are documented

• Effectiveness of the risk-screening model in detecting fraud based issues

• Technical soundness of risk-scoring in flagging potential fraudulent patterns and tendencies

• Partial support in the final product.

** Structural support for this feature is provided, but an active learning system is not deployed with the final application.

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SECTION 3: Licensing

Copyright 2012-2013 TopCoder, Inc.

This code was developed under U.S. government contract NNH10CD71C.

Licensed under the Apache License, Version 2.0 (the "License"); you may not use this file except in compliance with the License. You may obtain a copy of the License at: http://www.apache.org/licenses/LICENSE-2.0

Unless required by applicable law or agreed to in writing, software distributed under the License is distributed on an "AS IS" BASIS, WITHOUT WARRANTIES OR CONDITIONS OF ANY KIND, either express or implied.

See the License for the specific language governing permissions and limitations under the License. <<<<<<< HEAD

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Updating minor changes to README