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Program Integrity: Fraud & AbuseGlendon SchusterSenior Vice President and Chief Technology Officer

Alliance for Health Reform Panel BriefingMarch 5, 2012

“It is the policy of Centene Corporation to conduct its business affairs in

accordance with the standards and rules of ethical business conduct and to abide by all applicable laws, both in

letter and spirit.

In this, there is no compromise.” - Michael F. Neidorff

Chairman, President and CEO

Program Integrity at Centene

Conventional Methods Preventive Approach

Supporting Program Integrity

Program Integrity – Conventional Methods

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Centelligence™Through Centelligence™ we take our conventional methods

of Program Integrity to the next level.

Centene Preventive Approach

Demand for faster, more accurate payment

provides opportunities for engagement.

Health Information Technology

Provider Partnerships

Coordinated Care

Collaboration with our State Partners

• Health Information Technology (HIT)– Administrative Efficiency / Electronic Data Interchange (EDI)– Electronic Health Records, Member Health Records, Personal

Health Records, Health Information Exchange

• Provider Partnerships– Provider Support – Electronic Claim Submission– Joint Venture Partnerships

• Care Coordination– Member Connections– Co-Location Provider Offices and FQHC– Case Management

• State Partnerships – Participate with other MCOs and State

If you can run the company a bit more collaboratively, you get a better result, because you have more bandwidth and checking and balancing going on.

Larry Page, co-founder of Google

Centene Preventive Approach

Program Integrity - Results

EMPLOYEE EDUCATION

An employee reported concerns that a home health agency may

have been billing for services that the Foster Parent was providing

to their Foster Child. A record review validated the allegation

and identified a potential overpayment of $1.3 million.

The provider was reported to OIG for potential fraud.

We identified an Ophthalmologist consistently billing procedures on five consecutive days to enrollees that

lived in the same apartment complex.

Review of the records indicated significant concern and the case was referred to the MFCU.