Healthcare News / Physmark

CareMaps – Improving Care While Detecting Fraud & Abuse

Via: ReleaseWire

Updated 8:00 AM CDT, Tue, October 29,2019

Almost $100 Billion await recovery in Medicaid programs

Corrales, NM -- (ReleaseWire) -- 10/29/2019 -- - Geographic maps of chronic diseases and cancer, their onset, spread and costs of treatment are displayed on a dashboard using Tableau's visual database, making it possible to find best care programs and use them to replace ineffective ones
- The pilot CareMaps analysis of a state's Medicaid program revealed unintended excessive premium payments to healthplans during the 2014 Medicaid expansion. This discovery enabled the state to recover $200 million.
- The error that CareMaps uncovered is difficult to detect. It is likely that similar excesses remain unnoticed in many of the other states that opted for Medicaid expansion. A conservative estimate of potential recovery is $100 billion.

Corrales, NM, October 29, 2019: CareMaps developed by Physmark, Inc. and distributed by Care Maps, Inc., is now available on Tableau's visual database. CareMaps creates and displays geographical maps of chronic diseases and cancer, their spread, the rate at which they spread, and their treatment costs. CareMaps is based on a patented dynamic forecasting model, and its 12-month forecasts of the numbers of people who develop these conditions, and the estimates of medical costs for the population, have less than 5% error. A formidable forensic tool, CareMaps can contemporaneously identify anomalous treatment costs that are often precursors of waste, fraud and abuse.

CareMaps analyzes de-identified healthcare claims data to create a chronic disease and cancer atlas. "The Dartmouth Atlas tracks costs in fee for service programs while CareMaps plays a similar role in managed care, where the disease, its severity, treatment outcomes and costs are simultaneously displayed" said Dr. Jacob Kuriyan, founder of Physmark, Inc., and Care Maps, Inc. Available on a Tableau dashboard that uses a visual database that can be queried, CareMaps is a tool that grades the health status of communities and measures performance of care programs. It can help in the timely replacement of poorly performing programs, saving money and improving health of communities.

While actuaries view premium calculations as trade secrets, CareMaps' proprietary technology converts premiums to equivalent treatment costs of diseases. In the pilot analysis of Medicaid data in a state, the 2014 treatment costs inferred from premiums were 20% higher than prevailing market prices. The state's mandatory year-end audit failed to detect these overpayments. Under the Federal False Claims Act, healthplans are required to voluntarily detect and return excess payments at year-end. Retention of overpayments, even if unintentional, constitutes fraud. CareMaps' discovery of overpayments, led to recovery of more than $200 million from the healthplans. "Thirty-five other states opted for Medicaid expansion, under the Affordable Care Act (ACA), and based on our analysis, a conservative estimate of fraud awaiting recovery is in excess of $100 billion," said Dr. Kuriyan. "CareMaps can play an important role in identifying this fraud," added Dr. Kuriyan.

This result also resolves two enduring puzzles. First, the ACA, in spite of $25 billion in cost reduction initiatives, failed to make care affordable. Why? It turns out they ignored the cardinal rule: reductions in total costs are possible if, and only if, premiums can be lowered. Exotic initiatives that ACA launched – like, value based or shared savings programs – merely shuffle profits amongst stakeholders without lowering premiums appreciably.

Second, there is the claim from CMS (Center for Medicare and Medicaid Services) that fee for service fraud and abuse rate is 12.9% while managed care has reduced it to a low 0.3%. The GAO (Government Accountability Office) has attributed this anomaly, not to mitigation of fraud and abuse, but to poor efforts at detecting such risk. (https://www.gao.gov/assets/700/691619.pdf). CareMaps' discovery of almost 8% fraud and abuse supports GAO's inspired guess.

Premiums are a mystery, not just in Medicaid, but in all managed care programs. Medicare Advantage, HMOs, large self-insured employers and state and local organizations can benefit from CareMaps' interpretations of premiums. With the accumulation of huge volumes of data, and large numbers of users dispersed nationally, a centralized repository deployed in a cloud is critically important to offer both rapid access and updates in a secure environment. Cloud based benchmarks for performance of prevention programs and costs of treatments will be invaluable in all of healthcare.

About Physmark, Inc.
Physmark, Inc., a healthcare software company, used its patented chronic population model to develop CareMaps. Care Maps, Inc. has the exclusive rights to market CareMaps. Both companies are based in Corrales, New Mexico. CareMaps uses Tableau's visual database to create its dashboard and graphs. Salesforce.com, Inc. (NASDAQ:CRM) acquired Tableau in August 2019. Tableau is deployed in the cloud in multiple ways. https://help.tableau.com/current/server/en-gb/ts_tableau_server_cloud_overview.htm
Besides Tableau's hosted environment in the cloud, Tableau server can be installed on Amazon web services (NASDAQ:AMZN), Alphabet's Google cloud platform (NASDAQ:GOOGL) and Microsoft (NASDAQ:MSFT) Azure. For more information on CareMaps please visit http://www.physmark.com or email jkuriyan@physmark.com.

For more information on this press release visit:
http://www.releasewire.com/press-releases/caremaps-improving-care-while-detecting-fraud-abuse-1263490.htm

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