Doctor Shopping and Real-time, Cross-state Prevention with Castlestone

1,606 views

Published on

PMPs are manually intensive, difficult to use systems that cannot look across state lines. They "inspect and correct" transactions AFTER they occur, usually after tens or hundreds of a type occur, before a pattern emerges. They then correct only the most notable/egregious violations. At best their information is days old when used by doctors and pharmacists.

Castlestone works on a simple card-swipe as in a retail store, works across the nation,and works in real-time - documents all prescriptions as they are written, prevents bulk writing, duplicate writing, and, Castlestone prevents filling false prescriptions, INCLUDING cash payment transactions.

0 Comments
1 Like
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total views
1,606
On SlideShare
0
From Embeds
0
Number of Embeds
31
Actions
Shares
0
Downloads
2
Comments
0
Likes
1
Embeds 0
No embeds

No notes for slide

Doctor Shopping and Real-time, Cross-state Prevention with Castlestone

  1. 1. Proprietary and Confidential Intellectual Property of Castlestone Advisors LLC © 2015 Preventing Doctor Shopping and Opioid Abuse A special case of Fraud, Waste and Abuse in Health Care May 28, 2015
  2. 2. With the increased attention on opioid abuse many have called for material improvements in the Prescription Monitoring Programs (PDMPs) Aims for PDMP’s include:  Better Use and usability  Real-time reporting  Interoperability (across states) Castlestone’s uses electronic health cards and location verification to:  Collect information about prescriptions as they are being filled in real time  Without this enterprising doctor shoppers can visit many pharmacists and fill many prescriptions before PMP records catch up  Collect information about prescriptions as they are written, also in real time  Enterprising doctor shoppers can visit many doctors and acquire many prescriptions before PMP records catch up.  Stops pill mills and “rogue physicians and pharmacists” from writing/filling more prescriptions than time and geography permit  Use our native interstate capability to capture prescription and dispensing transactions anywhere  Feed any and all of this to PDMPs and state agencies  Easy, simple card swipe, no new capital technology or software 1 Proprietary and Confidential Intellectual Property of Castlestone Advisors LLC © 2015
  3. 3. With Castlestone - At the Doctor’s Office the patient, the doctor, the location, the transaction type and time are verified and captured with a simple card swipe 2. Data on Card ID, Terminal Owner, Terminal Location Merchant Code, Transaction Code, Time Stamp (via credit card network infrastructure) 1. . Patient and doctor swipe card Doctor keys trans. code for Schedule II prescription Castlestone runs rules against each swipe, in real time, e.g.: • Verifies the swipe terminal is in our database of providers as a medical merchant code` • Determines if card been reported lost or stolen or has restrictions • Determines when/where card was most recently swiped elsewhere • Determines if card holder already been issued a prescription for a Class II or Class III drug 2 Proprietary and Confidential Intellectual Property of Castlestone Advisors LLC © 2015
  4. 4. Then, these data can be matched versus existing claim and prescription records looking for duplicates, multiples, matches 2. Data on Card ID, Terminal Owner, Terminal Location Merchant Code, Transaction Code, Time Stamp 3. Claim Matching • Recipient name • HealthPlan ID • Provider ID • . Health Insurer’s Analytics (Can include PMP analytics) Card Swipe Details Card Number: 5424176022824317 Name: Mitchell Clark HealthPlan ID# 6789b Provider ID# 0077464 Swipe Terminal ID9443C3002846 (registered to Dr. Byron Black) Date of Transaction:1/15/14 Time of Transaction 10:06:23 Claim Details Recipient Name Mitchell Clark Name: Mitchell Clark HealthPlan ID# 6789b Provider ID# 0077464 Provider Name: Byron Black, MD Date of Service:1/15/14 1. . Patient and doctor swipe card Doctor keys trans. code for Schedule II prescription 4. Notification of existing prescription stolen card, Or other flag; can be sent directly to PMP-defined screen, etc. 3 Proprietary and Confidential Intellectual Property of Castlestone Advisors LLC © 2015
  5. 5. When referred, the doctor and/or the patient is contacted before the transaction is approved 2. Data on Card ID, Terminal Owner, Terminal Location Merchant Code, Transaction Code, Time Stamp 3. Claim Matching • Verify terminal code • Verify medical merchant code • Lost or stolen card? • Previous time and location of swipe • Existing Rx for Class II drug?, etc. 4. Approve, Deny or Refer 5. On referral, verify before taking action, guide to counseling , or take other action as appropriate Health Insurer’s Analytics (Can include PMP analytics) 1. . Patient and doctor swipe card Doctor keys trans. code for Schedule II prescription 4 Proprietary and Confidential Intellectual Property of Castlestone Advisors LLC © 2015
  6. 6. Card Swipe Details- Doctor’s Office Card Number: 5424176022824317 Name: Mitchell Clark Plan ID# xxx-xx-6789 Prescriber ID# 0077464 Prescriber Name: Richard Howard, MD Rx Date: 1/15/14 Order Code: 11551 Claim Details Recipient Name Mitchell Clark Name: Mitchell Clark HealthPlan ID# 6789b Provider ID# 0077464 Provider Name: Byron Black, MD Date of Service:1/15/14 At the Pharmacy: Castlestone logs the prescription at the time it is written and verifies for the pharmacist prior to filling Card Swipe Details- Pharmacist Card Number: 5424176022824317 Name: Mitchell Clark Plan ID# xxx-xx-6789 Supplier ID# 0088444 Supplier Name: ABC Pharmacy, Trenton NJ Date: 1/15/14 Order Code: 11551 • Verifies doctor visit • Verifies prescription information • Verifies pharmacy • Attests that physician order came from physician office • Location verification of pharmacy • Time of filling prescription • Blocks order after fill of proper quantity (prevent alteration) • Blocks fill within time parameters 5 Proprietary and Confidential Intellectual Property of Castlestone Advisors LLC © 2015
  7. 7. Castlestone implementations comply with standards for PDMP-EHR integration PDMP Hub EHR PDMP EHR Standard: ASAP Web Services (preferred) HL7 v2 NCPDP SCRIPT PDMP Standard: PMIX-NIEM  Delivers findings directly to physician via EHR system  Shares all transactions with PDMP 6 Proprietary and Confidential Intellectual Property of Castlestone Advisors LLC © 2015
  8. 8. Cost and implementation considerations include:  Card Creation  Castlestone creates/activates/deactivates and manages cards based on guidelines. Plan Sponsor existing card manufacturing contracts can be used if they are compatible  Hardware cost for plan & providers  NONE. Uses existing credit card terminals  Network costs for plan & providers  NONE. Uses the existing credit card networks from provider offices for transactions  Systems & programming costs  S&P is very simple data exchange of new/change/delete clients or full real time integration  Cost Structure  Design and programming & card cost  Hosting (data base & monthly hosting and management)  Per transaction fees 7 Proprietary and Confidential Intellectual Property of Castlestone Advisors LLC © 2015
  9. 9. Timeframe and typical results  Set up completely implemented in 60-75 days, depending upon client resources  All technical milestones (transaction capture, claim matching, file and interface implementation) exceed goals for speed and performance  ROI for fraud prevention is in the hundreds of percents  Elimination and/or disabling of many false prescriptions, most notably intra- day doctor shopping and intra-state frauds/mis-use  Easier, more accurate access to PDMP information aiding diagnosis and medical advice processes  Reduction in rates of new addiction and the downstream medical, legal, social and family costs  Able to integrate with rehabilitation treatment plans  Able to combine information from a similarly configured medical cannabis enabled management process 8 Proprietary and Confidential Intellectual Property of Castlestone Advisors LLC © 2015
  10. 10. Castlestone’s request of Health Departments and legislatures 1. Examine the service offering more closely in the context of the value of real-time, intra-state, location-verified processes  Develop hypotheses on the impact and value, tangible and intangible, to patients, providers and the community at large 2. Determine a community/market to test the hypotheses 3. Run and refine the test, run it again, implement widely as the case benefits become clear 9 Proprietary and Confidential Intellectual Property of Castlestone Advisors LLC © 2015
  11. 11. Contacting Castlestone Doug Brockway Business Development – New England Castlestone Advisors LLC (617) 834-0067 dbrockway@advancecons.com Jeff Leston President Castlestone Advisors LLC (212) 874-4390 Jeff@castlestone-llc.com 10 Proprietary and Confidential Intellectual Property of Castlestone Advisors LLC © 2015
  12. 12. Other uses of Castlestone you may find of interest include: Title Link Fraud Prevention for Health Insurers http://slidesha.re/1pCGh98 Doctor Shopping and Prevention http://slidesha.re/1nNb9OL CMS Pilot/Test of VisitEye http://slidesha.re/1vlGGeU Management Tech. for Therapeutic Cannabis http://slidesha.re/1nQ5JkD Corporate Wellness http://slidesha.re/1qQf6Fi 11 Proprietary and Confidential Intellectual Property of Castlestone Advisors LLC © 2015
  13. 13. Without location verification an array of fraud, waste and abuse goes undetected Submitted Claims Payments Data Analytics Investigation, Compliance, Enforcement & Prosecution (Large cases only) • Services not rendered • Misrepresented o Date of service o Location of service o Provider of service • Waiving of deductible or copayments • Duplicate prescriptions • False or inappropriate prescriptions • False or inappropriate fulfillment and re-fills • Billing for non-covered service • Incorrect diagnosis & bundling • Overutilization • Kickbacks and bribery 6.7% to 10% of Claims Claim prep & submit Claim validation & analysis Outpatient Services • Clinic • Lab • Imaging • Physical Therapy • Mental Therapy • Home Care • Transport- ation • Pharmacy 12 Top 10 healthcare fraud schemes: http://www.acfe.com/article.aspx?id=4294976280 Proprietary and Confidential Intellectual Property of Castlestone Advisors LLC © 2015
  14. 14. Castlestone’s location verification, real time & other analyses eliminate a great deal of fraud, waste & abuse Submitted Claims Payments HIGHLY FOCUSED Investigation, Compliance, Enforcement & Prosecution 6.7% to 10% of Claims Claim prep & submit Claim validation & analysis Outpatient Services • Clinic • Lab • Imaging • Physical Therapy • Mental Therapy • Home Care • Transport- ation • Pharmacy • Only pay claims with real, i.e. swiped, patient and provider • If claim data do not match swipe data, deny or refer claim • Now, smaller, infrequent and one-off frauds are also stopped Enhanced POS rules Data Analytics • Services not rendered • Misrepresented o Date of service o Location of service o Provider of service • Waiving of deductible or copayments • Duplicate prescriptions • False or inappropriate prescriptions • False or inappropriate fulfillment and re-fills • Billing for non-covered service • Incorrect diagnosis & bundling • Overutilization • Kickbacks and bribery 13 Proprietary and Confidential Intellectual Property of Castlestone Advisors LLC © 2015
  15. 15. Outpatient process for wellness or rehabilitation: When the participant uses a wellness service • Authorized provider & Location • Service/procedure provided matches plan • Time and date of service/procedure We now have a record of: • A verified location for each office visit • The time and date it of the visit • Match of the service/activity code to the program options If there is no card, the provider office can register a new card for the patient on program portal 3) Castlestone compares swipe with the patient’s program 1) Provider swipes recipient card 2) Provider enters Service/Activity Code • Patient ID • Prescribing Physician ID • Service Code • Service Location • Service Date 14 Proprietary and Confidential Intellectual Property of Castlestone Advisors LLC © 2015
  16. 16. Using electronic health cards medical marijuana certifications are up-to-date and applied in real time Eligibility Registration Treatment Management Clinic Patient • Provider Exam • Symptoms • Qualifying Condition Care Giver • Background Check Certification Criteria HHS Registry • Patients • Caregivers • Clinics • Renewals and on- going eligibilities • Prevention of Shopping • Doctors • Care Givers • Clinics • Inventory • Reporting • Inventory • Trends • Demographics • Outcomes Purchase by Patient Purchase by Care Giver MedicalMarijuanaProcess Card swipes at certification and at sale record and verify 15 Proprietary and Confidential Intellectual Property of Castlestone Advisors LLC © 2015

×