As an integral part of the Medicare Integrity Program (MIP) activities, Highmark Medicare Services' Data Services Unit (DSU), the data analysis arm of the Medical Policy & Information Development (MPID) department performs several key functions.

KEY FUNCTION 1: PRO-ACTIVE DATA ANALYSIS

Pro-active data analysis represents the data analysis efforts identifying issues within the Medicare system that may be at-risk for fraud, abuse, or billing errors. The DSU performs pro-active analysis by utilizing statistical analysis techniques (such as regression) and/or following leads or concerns raised by others from both inside and outside Highmark Medicare Services. Pro-active data analysis is an activity that the DSU performs year-round supporting the Provider Education & Training and Medical Review functions. The DSU follows nearly a dozen different protocols, procedures and guidelines as it performs and completes over 30 proactive analyses each year. Upon completion of such an analyses, the DSU provides a summary of its findings and recommendations to Highmark Medicare Services's cross-functional MIP team to determine appropriate progressive corrective actions. Common outcomes include education and audits.

KEY FUNCTION 2: MIP COMMITTEE ADMINISTRATION

The DSU serves as the coordinator of, and clearinghouse for, all MIP Committee related activities and information. The MIP Committee is an interdisciplinary team that meets regularly to discuss and review new data findings, brainstorm regarding potential areas of vulnerability in the Medicare program, and provide recommendations for progressive corrective actions and future pro-active data analyses.

KEY FUNCTION 3: AD HOC DATA REQUESTS

Processing ad hoc data requests is a central function of the DSU. Our primary internal customers requesting these ad hocs include the Medical Review Department, and the Office of Medical Affairs, which includes our Carrier Medical Director. They utilize the information contained in these reports in support of their casework, discussions with providers, and management decisions. Our primary external customers requesting these ad hocs include the FBI, the GAO, the OIG, and Highmark Medicare Services (the Part A Intermediary in Pennsylvania). Completion of ad hoc requests is strictly governed by internal quality control protocols. The protocols cover issues from timeliness, accuracy, programming logic and debugging validation checkpoints, data source and output validation procedures, research and analysis due diligence, and appropriate documentation.

KEY FUNCTION 4: DATA EXPERTS

The DSU serves as the Highmark Medicare Services Data Warehouse (DW) custodian. We are responsible for insuring the integrity and accuracy of this data source for Pennsylvania Medicare Part B operations. As such we have extensive guidelines and procedures we use in its testing. In addition to being the custodian of this data for Highmark Medicare Services, we are also the primary resource for any questions relating to data. The DW is our main source of internal data.

KEY FUNCTION 5: STATISTICAL SUPPORT

The DSU provides statistical support for Medical Review in two key areas: statistical sampling and overpayment calculations based on extrapolation. Statistical samples are chosen in accordance with the type of case MR is working. Extrapolation calculations are needed primarily for estimating a total overpayment amount based on a review of medical records. Because sampling and extrapolation are closely related, DSU insures that proper calculations are utilized during the entire process.