Provider Resources, Inc. (PRI) Services
- Program Integrity Solutions
- Healthcare Quality Solutions
- Education Solutions
- Conference Planning Solutions
- Support in the Development of Information Technology
PROGRAM INTEGRITY SOLUTIONS
Our understanding of and performance in matters of program integrity is demonstrated by our on-going Office of Workers Compensation (OWCP) claims reviews in support of the federal government. In this effort, we augment government investigations staff by our post-payment review & analysis of claimant medical records and related bill-payment documentation. Further, we provide trial support through expert testimony and analyses concerning our work product. We also provide support of the civil and criminal resolution of these matters under the direction of the both the investigative agency and the various offices of the United States Attorney. The medical reviews of these claimant files, as performed by PRI experts, support major federal investigations of suspected false claims and related offenses for medical services alleged to have been properly provided to former federal employees receiving OWCP benefits. PRI employees have a documented history of highly-qualified training and field experience in the identification, investigation and prosecution of both criminal and civil healthcare fraud.
The involvement of PRI assets in program integrity is also demonstrated through our support of the Medicare Zone Program Integrity Contractors (ZPIC) program. This support involves the application of our clinical review of medical records by PRI experts, coupled with other PRI expert understanding of medical coding and billing requirements. We also provide physician-level quality assurance for these reviews. The results delivered by PRI staff are critical to the ZPIC process of identifying individual and systemic patterns of fraud, waste & abuse within the geographic boundaries of the ZPIC initiative.
As CMS sought to eliminate fraud, waste & abuse within the Medicare program, a national recovery of provider overcharges was established through the Recovery Audit Contractors (RAC) program. Once again, CMS looked to PRI to perform the critical quality control function of this program as the RAC Validation Contractor (RCV). In performing this work, PRI applies its considerable depth of Medicare knowledge and expertise on behalf of CMS to validate those efforts of the Medicare RACs. Our medical review teams—paired with our Medicare policy and procedures experts—audit the RACs’ determinations for Medicare claims which were paid under Part A or Part B of title XVIII of the Social Security Act. Through its reports to CMS, PRI ensures that the RACs are not unnecessarily denying Medicare claims which were properly paid. Similarly, our findings can also assure CMS that the RACs are properly recovering improperly-paid claims.
Moving forward with this program, PRI leadership continues to develop and implement a rigorous review process with multiple levels of review for each proposed audit guideline and sample claim determination. The PRI personnel assigned to this work are provided with ongoing training. Through the efforts of its experts, PRI has produced and continues to produce results within the healthcare system which identify potential fraud, eradicates waste and unnecessary duplication, and demonstrates a judicious use of taxpayer dollars. PRI is also positioned in its Program Integrity work to provide education to healthcare stakeholders such as government agencies and healthcare providers, among others.
HEALTHCARE QUALITY SOLUTIONS
Matching our passionate interest of building integrity into the healthcare system, PRI possesses a strong commitment to assuring the highest levels of quality healthcare for all stakeholders and working in a collaborative manner. Once again, the careful composition of our team of national healthcare experts exhibits the flexibility and diverse specialization that further defines our company, our quality component.
Because of our program personnel and our staff of M.D.s, Ph.D.s, R.N.s, pharmacists, and expert-level certified coders, PRI is able to precisely meet its clients’ needs. PRI is on the leading edge of understanding the pending requirements of the new ICD-10 coding series and ensures that our capabilities include expert-level knowledge of the significant differences associated with this changeover from current ICD-9 requirements. Working with CMS, PRI has developed and implemented a collaborative model for working with states in order to improve the quality of those states’ neonatal healthcare. That quality improvement work involves evidence-based treatment effectiveness in support of Medicare and Medicaid, geographically-based issues concerning infant mortality rates, increased pre-natal education and care, and neonatal measures designed to improve new born care. From these studies and the continued presence of PRI project management and subject matter experts, the Medicaid program will be better equipped to identify and serve the needs of these important and often-underserved beneficiaries.
We have provided peer review and analysis of physician-level treatment protocols for a federal agency, which was reflective of its national scope. Our personnel have supported the policies and practices of the Medicare program, accomplished by communicating Medicare policies and procedures to Congress, healthcare facilities, plan beneficiaries, healthcare plans, medical and specialty providers and provider group associations. Similarly, the application of our knowledge of Medicare’s fee-for-service programs and the Medicare Advantage & Prescription Drug Plan has contributed to cost savings, excessive capitation payments, and created mechanisms to prevent low quality managed-care practices.
Our presence in emerging national plans to improve healthcare through ensured portability and accuracy of medical record keeping is evident as CMS once again sought PRI as its choice to measure the meaningful use of electronic health records during the national comment period. The support of such national healthcare dynamics by PRI demonstrates and validates our recognized commitment to improving healthcare quality measures.
EDUCATION SOLUTIONS
The recruitment and accrual of so many nationally-recognized and diverse experts by PRI has projected our company as a leader in educational solutions for both the public and private sectors. Our experts have been invited as presenters and speakers, as well as authors of white papers, for leading national conferences on healthcare integrity and quality subjects. As well, PRI experts have also testified before Congress concerning the implementation and impact of emerging Medicare policies and procedures.
Many of our PRI subject matter experts have led in the facilitation of workgroups, designed training manuals, and created learning modules for audiences such as CMS employees and Plan Sponsors, Medicare beneficiaries, facilities, and providers/provider groups in order to aid in the understanding and correct application of a variety of Medicare regulations and policies. PRI’s knowledge of the Medicare fee for service, Medicare Advantage – Prescription Drug Plans, Medicaid fee for service, and Medicaid managed care program operations and management has in the past aided the State of Ohio and District of Columbia Government, Medicaid PBM vendors, MMIS vendors, and Disease Management Contractors in designing and implementing policies to reduce improper payments for the Medicaid and Medicare Programs.
Our experts have been able to facilitate cost savings, identify excessive capitation payments and create mechanisms to prevent both poor quality managed-care fraud practices and receipt of improper payments. Our medical necessity reviews are conducted or managed by board certified physicians. PRI currently works cooperatively with the USPS-OIG, in accordance with the OWCP guidelines and regulations, to perform medical reviews of claimant records in order to determine if services paid are supported by medical record documentation for their related bill payment data. Similarly, CPT and related codes are reviewed to determine that billings reimbursed through OWCP are correctly coded and reimbursed.
CONFERENCE PLANNING SOLUTIONS
PRI has assembled and demonstrated the capacity to successfully plan and execute conference and educational training events on both a national and regional level. Our staff is comprised of qualified conference planners and managers who understand how to determine and merge client needs with appropriate private sector assets to produce events in a positive learning environment.
PRI understands and has demonstrated the importance of conducting sufficient analysis of needs, not only of the client but of the intended audience of such events. As such, we understand the process for developing content of such conferences and training opportunities and how to utilize available commercial space resources to best-present these information sharing exercises. We are fully capable of developing conference and training promotional concepts, effective marketing strategies, complete on-line pre-registration services, agenda preparation, and event follow-up surveys.
We understand and have implemented technology-based solutions in every aspect of conference and training planning and presentation. PRI has significant understanding of capturing audio and video files of presentations such that our archiving of event material can be achieved after complete post-production editing. As a result of these capabilities, we are capable of delivering and maintaining web conferencing portals for sharing event materials with non-resident audience members in a combination of delivery platforms, including 508-compliant .pdf, .mp4 and .mp3 files. We can also offer video captioning and Spanish translations, when necessary.
SUPPORT IN THE DEVELOPMENT OF INFORMATION TECHNOLOGY
With PRI’s broad knowledge of the healthcare system, it is only natural of our ability to support the development of Information Technology, which is the foundation upon which our healthcare system today rests. PRI’s work on the Nationwide Health Information Network Trial Implementation (NHINII) saw us working to improve patient safety, healthcare quality and cost through the adoption of health information technology and clinical best practices. Here, PRI also identified requirements for Electronic Health Records (EHR) which can enhance data protections, such as increased data validity, accuracy and integrity; appropriate fraud management; and effective fraud detection. PRI employs experts who have worked with Office of the National Coordinator for Health Information Technology (ONC) and who are actively engaged in the changes currently being made in the healthcare industry relevant to health information technology. PRI also works on CMS’ MU/EHR Incentive Program, a project for which ONC has written the companion document.