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Published by alicia.luckett, 2019-10-23 13:23:07

Book Design

WWW.HFPP.CMS.GOV

Together, we work to
identify and reduce fraud,
waste, and abuse across

the healthcare sector.

ABOUT THE HFPP HFPP OBJECTIVES

The HFPP is a voluntary, public-private To deliver unique cross-payer analyses of
partnership between the federal govern- healthcare data across the Centers for
ment, state and local government Medicare & Medicaid Services (CMS), state
agencies, law enforcement, private health Medicaid offices, and private payers. To
insurance plans, employer organizations, identify potential savings that Partners
and healthcare anti-fraud associations cannot identify in their data alone.To
that seek to identify and reduce fraud, increase detection of fraud, waste, and
waste, and abuse across the healthcare abuse across the private and public
sector. healthcare spectrum.

HFPP partners regularly collaborate, share A UNIQUE
information and data, and conduct studies PARTNERSHIP
using a unique cross-payer data set. Given
the HFPP’s broad membership encom- HFPP’s studies enable Partners to take
passing a variety of players interested and substantive actions to stop fraudulent and
involved in detection of fraud, waste, and improper payments from going out the
abuse in the healthcare system, it is door.HFPP provides Partners with broader
uniquely positioned to examine emerging visibility into the universe of payments
trends and develop key recommendations beyond those issued by a single
and strategies to address them. payer.Partners work with experts to
identify emerging threats and design new
methods to combat them.

2

THE HFPP ELIGIBLE
CURRENTLY HAS * PARTICIPANTS

145 PARTNERS The expectation is that Partners will actively
48 participate in and meaningfully contribute
to the activities of the Partnership. Interest-
STATE & LOCAL ed entities should be willing and able to
PARTNERS share data or contribute relevant informa-
tion and insights with the Partnership.
71 Entities covered by the Health Insurance
Portability and Accountability Act (HIPAA)
PRIVATE PAYERS requirements are eligible to participate in
HFPP studies.
13
JOINING THE
FEDERAL AGENCIES PARTNERSHIP

13 After the initial vetting process, each
Partner organization is required to execute
ASSOCIATIONS a Memorandum of Understanding (MOU),
which describes the purpose and objectives
HFPP’s studies enable Partners to of the HFPP as well as the roles,
take substantive actions to stop responsibilities, and expectations of each
fraudulent and improper payments Partner organization.
from going out the door. Additionally, each Partner that wishes to
submit data and participate in HFPP
HFPP provides Partners with studies must execute a Data Sharing
broader visibility into the universe Agreement (DSA), which sets expectations
of payments beyond those issued for security and privacy safeguards and
by a single payer. conditions under which data is submitted,
aggregated, shared, and reported. The DSA
Partners work with healthcare fraud is executed with the TTP, currently operated
experts to identify emerging threats by GDIT.
and design new methods to Upon execution of these agreements, the
combat them. organization is granted full Partner status
and begins the onboarding process.

3

HFPP Frequently Asked Questions

WHAT ARE THE BENEFITS OF JOINING THE HFPP?

ENHANCED DATA ANALYTICS EXPANDED RESEARCH

The HFPP is the only organization through Partners inform study criteria and designs
which Partners can combine their data for maximum impact, joining forces to
address emerging trends with fraud,
with public and private data, including the waste, and abuse implications.
Centers for Medicare & Medicaid Services
(CMS), in order to gain heightened insights

into fraud, waste, and abuse.

CONFIDENTIALITY & SECURITY COLLABORATION

A Trusted Third Party (TTP) enforces the Through a variety of HFPP events
security and de-identification of Partner including Regional Information Sharing
data. No Partner – public or private – has Sessions and webinars, Partners leverage
their collective experiences to shape the
access to the data of other Partners.
future of the Partnership and combat
healthcare fraud across the nation.

IS THERE A FEE TO JOIN THE HFPP? DID YOU KNOW?

There is no cost to join the Partnership or to HFPP Partner data includes
participate in HFPP-sponsored events, studies,
or activities, with the exception of any travel more than 74 percent of
costs you may incur.
covered lives in the United States.

WHO IS ELIGIBLE TO PARTICIPATE IN HFPP EVENTS AND ACTIVITIES?

All Partners are encouraged to participate in and meaningfully contribute to HFPP
activities. This includes being willing and able to share data, relevant information and
insights. Entities covered by the Health Insurance Portability and Accountability Act
(HIPAA) requirements are eligible to participate in HFPP studies.

HOW CAN OUR ORGANIZATION JOIN THE HFPP?

After the initial vetting process, each Partner organization is required to execute a
Memorandum of Understanding (MOU), which describes the purpose and objectives of
the HFPP as well as the roles, responsibilities, and expectations of each Partner organiza-
tion. Additionally, each Partner that wishes to submit data and participate in HFPP studies
must execute a Data Sharing Agreement (DSA), which sets expectations for security and
privacy safeguards and conditions under which data is submitted, aggregated, shared,
and reported. Upon execution of these agreements, the organization is granted full
Partner status and begins the onboarding process.

4

HFPP Frequently Asked Questions

HOW CAN A PARTNER TAKE FULL ADVANTAGE
OF HFPP MEMBERSHIP?

All Partners are encouraged to participate in and meaningfully contribute to HFPP
activities. This includes being willing and able to share data, relevant information and
insights. Entities covered by the Health Insurance Portability and Accountability Act
(HIPAA) requirements are eligible to participate in HFPP studies.

CONTRIBUTE DATA SHARE IDEAS AND PARTICIPATE
IN STUDY DEVELOPMENT
Share your data for use in anti-fraud,
waste, and abuse studies to help increase Share ideas and fraud schemes that can
be developed into study designs.
the impact of our results and findings.
Increase your own capabilities and skills
by helping to advance and refine the
methodologies and analytics used in
HFPP studies.

ATTEND EDUCATIONAL PROVIDE STUDY OUTCOMES
AND NETWORKING EVENTS AND ACTIONABLE RESULTS

Share your outcomes and actionable Share your outcomes and actionable
insights to help the HFPP better insights to help the HFPP better
understand how it can enhance understand how it can enhance

Partner support, increase overall value, Partner support, increase overall value,
and quantify the return on investment and quantify the return on investment

for study participants. for study participants.

WHAT DATA DO STUDY PARTICIPANTS NEED TO PROVIDE?

The TTP provides a default standard for collecting claims data, while allowing Partners
flexibility in format, timing, and submission details. The TTP is currently processing
professional claims, actively requesting institutional claims, and plans for collecting
pharmacy and dental claims for the future. Partners are initially asked to submit two
years’ worth of data, along with periodic updates relevant
to the specific study.

HOW FREQUENTLY ARE STUDIES CONDUCTED?

The number of studies that the HFPP completes per year varies based on a variety of
factors, such as the level of Partner participation and data sharing, and the size and
complexity of the studies.

5

HFPP Frequently Asked Questions

WHAT DO HFPP STUDIES CONSIST OF?

HFPP studies provide Partners with actionable information about healthcare
system-wide issues. Through an agile approach, HFPP studies:

Apply research methodologies to claims data from public and private sectors.
Analyze and compare trends across multi-payer environments.
Deliver payer-level and aggregate results that are meaningful and reliable.
Examples of upcoming HFPP studies include those that identify providers who:
Continue to bill multiple payers after they are deactivated by the National
Provider and Plan Enumeration System (NPPES).
Bill an impossible amount of timed E&M services across payers.
Bill inappropriate amounts of sleep studies across payers.

WHAT TYPES OF INFORMATION WILL THE HFPP TTP PROTECT?

The TTP protects all HFPP Partners’ Information — including sensitive and proprietary
information — as defined in the MOU and DSA.

WHAT DATA SECURITY MEASURES ARE IN PLACE?

The HFPP has an external party perform a standard security attestation that reflects the
expected security and privacy safeguards. These security and privacy controls protect
sensitive information as defined by Federal Information Processing Standards (FIPS)
Publication, National Institute of Standards and Technology (NIST) Special Publication,
Security and Privacy Controls for Federal Information Systems and Organizations, and
the CMS Acceptable Risk Safeguards (ARS).

Sensitive information is protected by the TTP’s Security and Privacy Program (S&PP).
The S&PP controls were independently assessed, and the resulting security and privacy
posture and risk profile were evaluated and accepted by CMS. The S&PP continuously
monitors and improves controls in response to emerging threats and vulnerabilities.

The S&PP is owned and operated by the TTP and has received Authorization to Operate
(ATO) from CMS. To preserve Partner equities and interests, CMS has accepted the TTP’s
ATO to operate the S&PP independently of CMS. Partners preserve their ownership of,
rights to, and interests in their data as defined in the MOU and DSA.

6

HFPP Members

13 FEDERAL PARTNERS

U.S. Department of Defense, Defense Health Agency • U.S. Department of Health and Human Services,
Associate Deputy Secretary’s Office • U.S. Department of Health and Human Services, Centers for
Medicare & Medicaid Services • U.S. Department of Health and Human Services, Office of Inspector
General • U.S. Department of Justice, Criminal Division • U.S. Department of Justice, Federal Bureau of
Investigation • U.S. Department of Justice, Office of the Inspector General, Fraud Detection Office • U.S.
Department of Labor, Federal Employees’ Compensation • U.S. Department of Veterans Affairs, Office of
Inspector General • U.S. Department of Veterans Affairs, Veterans Health Administration • U.S. Food and
Drug Administration, Office of Criminal Investigations • U.S. Office of Personnel Management, Office of
the Inspector General • U.S. Postal Service, Office of Inspector General

13 ASSOCIATIONS

America’s Health Insurance Plans (AHIP) • American Insurance Association (AIA) • Association for
Community Affiliated Plans (ACAP) • Association of Certified Fraud Examiners (ACFE) • Blue Cross and
Blue Shield Association (BCBSA) • Coalition Against Insurance Fraud (Coalition) • Delta Dental Plans
Association (DDPA) • National Association of Insurance Commissioners (NAIC) • National Association of
Medicaid Directors (NAMD) • National Association of Medicaid Fraud Control Units (NAMFCU) • National
Business Group on Health (NBGH) • National Health Care Anti-Fraud Association (NHCAA) • National
Insurance Crime Bureau (NICB)

71 PRIVATE PAYERS

Aetna • AllWays Health Partners • Amerigroup • AmeriHealth Caritas • Anthem • Arkansas Blue Cross and
Blue Shield • ATRIO Health Plans • AvMed • Blue Cross Blue Shield of Alabama • Blue Cross Blue Shield of
Arizona • Blue Cross Blue Shield of Kansas • Blue Cross Blue Shield of Louisiana • Blue Cross Blue Shield
of Michigan • Blue Cross Blue Shield of Nebraska • Blue Shield of California • Boilermakers National
Funds • CareFirst Blue Cross Blue Shield • CareSource • Care N’ Care Insurance • Centene • Centers Plan
for Healthy Living • Central Health Plan of California • Cigna • Emblem Health • Evolent Health • Express
Scripts • Fidelis Care New York • Florida Blue • Fluent Health, LLC • Geisinger Health Plan (GHP)
• Government Employees Health Association (GEHA) • Health Alliance Plan (HAP) • Health Care Service
Corporation (HCSC) • Health First • Healthfirst, Inc. • Health Plan of San Joaquin • Health Plan of San
Mateo • HealthSun • Highmark • Horizon Blue Cross Blue Shield of New Jersey • Humana
• Independence Blue Cross • Kaiser Permanente • Magellan Health • Medica • Medical Mutual of Ohio
• MediGold • MedImpact Healthcare System • Meridian Health Plan • Moda Health • Molina Healthcare
• MVP Health Care • Navitus Health Solutions • New Directions Behavioral Health • Oscar Health
Insurance • Premera Blue Cross • Providence Health Plan • SCAN Health Plan • Sentry Insurance
• Steward Health Choice • SummaCare • The Hartford • Travelers • Tufts Health Plan • UnitedHealthcare
• Universal Care, Inc. • Vaya Health • Vision Service Plan (VSP) • Viva Health • WellCare Health Plans, Inc.
• WellMed Medical Management, Inc.

7

HFPP Members

48 STATE AND LOCAL PARTNERS

Alabama: Alabama Board of Medical Examiners • Alaska: Department of Health and Social Services

• Arizona: Arizona Health Care Cost Containment System, Office of the Inspector General • Arkansas:

Office of the Medicaid Inspector General • California: Central California Alliance for Health • California:

Department of Health Care Services • Colorado: Department of Health Care Policy & Financing

• Connecticut: Department of Social Services • District of Columbia: Department of Health Care

Finance • District of Columbia: Office of the Inspector General, Medicaid Fraud Control Unit • Florida:

Florida Agency for Health Care Administration • Hawaii: Department of Human Services, Med-QUEST

Division • Idaho: Department of Health and Welfare • Illinois: CountyCare, Cook County Health &

Hospitals System • Illinois: Department of Healthcare and Family Services, Office of the Inspector

General • Iowa: Department of Human Services, Iowa Medicaid Enterprise • Iowa: Insurance Fraud

Bureau • Iowa: Medicaid Fraud Control Unit • Kansas: Kansas Department of Health and Environment

• Louisiana: Louisiana Department of Health • Louisiana: Louisiana Office of Attorney General, Medicaid

Fraud Control Unit • Maryland: Department of Health and Mental Hygiene • Massachusetts:

Massachusetts Executive Office of Health and Human Services, Office of Medicaid • Massachusetts:

Office of the State Auditor • Michigan: Michigan Department of Health and Human Services, Office of

Inspector General • Minnesota: Minnesota Department of Human Services • Mississippi: Mississippi

Division of Medicaid • Missouri: Missouri Medicaid Audit & Compliance • Missouri: Office of the Missouri

Attorney General, Medicaid Fraud Control Unit • Montana: Department of Justice, Medicaid Fraud

Control Unit • Nebraska: Department of Health and Human Services, Division of Medicaid and LTC

• New Hampshire: New Hampshire Department of Health and Human Services, NH Medicaid Program

Integrity Unit • New Jersey: Office of State Comptroller, Medicaid Fraud Division • New York: Office of

the Medicaid Inspector General • North Carolina: Department of Health and Human Services, Division

of Medical Assistance • Ohio: Attorney General’s Office • Ohio: Ohio Department of Medicaid • Oregon:

Oregon Health Authority • Rhode Island: Executive Office of Health and Human Services • South

Dakota: Office of the Attorney General, Medicaid Fraud Control Unit • Tennessee: TennCare • Texas:

Health and Human Services Commission, Office of Inspector General • U. S. Virgin Islands: Department

of Human Services, Medicaid Program • Vermont: Department of Vermont Health Access, Program

Integrity Unit • Vermont: Office of the Vermont State Auditor • Washington: Washington State Health

Care Authority • West Virginia: Bureau for Medical Services • Wisconsin: Department of Health

Services, Office of the Inspector General * As of October 4, 2019

If you have other questions or are interested in joining the HFPP, please contact the
TTP Partner Engagement team at [email protected] or visit our website at hfpp.cms.gov.

For Internal Use by Healthcare Fraud Prevention Partnership (HFPP) Partners Only. The
following disclaimer applies: Regarding all HFPP communications and activities, this is a
purely voluntary activity. All data sharing and analysis forums; information sharing
sessions; and the Executive Board, are to be used solely as discussion groups where the
individual members can share facts or information or individual input. No group or
consensus advice or recommendations will be given and no policy-making or
decision-making will be performed by the partners. The Secretary and the Attorney
General or their designees will make the final policies or other decisions.


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