ODPANN 22-115 Nonreported and underreported Incident Detection using Medicaid Claim Data Administrative EntityODPANN 22-115

The Office of the Inspector General (OIG) conducted an audit in 2018-19 to determine whether Pennsylvania complied with Federal waiver and State requirements related to 24-hour critical incident reporting requirements for Medicaid beneficiaries with developmental disabilities that resided in community-based settings. The audit focused on controls to detect unreported critical incidents of beneficiaries by leveraging hospital and emergency room encounter claims that contain certain diagnosis codes that may be indicative of abuse, neglect, or other reportable incident events. In response, ODP set out to create a technology solution to fulfill the recommendations in the OIG Audit Report. In October 2021, ODP and Deloitte Consulting LLP released the Incident Reporting Fidelity Dashboard for internal use by ODP staff. The Incident Reporting Fidelity Dashboard links together ICD-10 diagnostic codes from Acute Care Facility and Emergency Room Medicaid claims data to corresponding incidents within the EIM System. This is done with the goal of detecting unreported critical incidents as well as estimating the prevalence of suspected incident underreporting. The dashboard not only identifies unreported and underreported incidents, but it also trends diagnosis patterns among beneficiaries and displays race and ethnicity trends, as well as geographies and patterns of providers. While the goal is to utilize tools across the entire waiver beneficiary population, ODP recognizes that provider incident reporting requirements are nuanced and vary depending on a variety of factors such as whether a beneficiary was receiving a provider-delivered service at the time of the Acute Care Facility or Emergency Room Visit encounter, the specific nature or cause of the encounter, or if there was suspicion that abuse or neglect occurred, may impact whether an encounter would require reporting in the EIM as a reportable incident. This work will be ongoing through implementation and therefore, ODP is approaching this oversight and monitoring activity in phases. ODP will continually evaluate the process for effectiveness and efficiency. For more information,  please see ODPANN 22-115.