Centers for Disease Control and Prevention, World Trade Center Health Program
OptumServe is honored to support the CDC’s World Trade Center Health Program Nationwide Provider Network (National Program) and William Street Clinic (New York Program). The program provides care to individuals who aided in the rescue, recovery and clean-up during the Sept. 11, 2001 attacks on the World Trade Center, Pentagon and Shanksville, PA.
Eligible responders and survivors who were exposed to environmental contaminants during the attacks have access to services such as health assessments, diagnostic testing, cancer screening, focused treatment, pharmacy benefits and case management. The programs serve more than 20,000 participating members who reside in New York and across the nation.
OptumServe is a proud partner with the Centers for Medicare and Medicaid Services (CMS), helping to maintain the CMS One Program Integrity (PI) system. One PI is the CMS enterprise resource created to identify, deter and prevent all fraud, waste and abuse activities across the agency. One PI supports more than 2,100 users requesting over 54,000 monthly data requests, resulting in millions of dollars of savings and program integrity improvements.
Additionally, the One PI system established an online interactive mapping tool to identify Medicare Part D opioid prescription claims within the U.S., allowing users to view opioid claims at the local level to understand how the epidemic is impacting communities.
CMS Medicare Access and CHIP Reauthorization Act (MACRA) Systems Integrator (SI) Contractor (MCSI)
OptumServe supported efforts by CMS in the way the agency compensates Medicare providers and assigns identification numbers to 60+ million Medicare beneficiaries.
Specifically, OptumServe provided support to CMS for the Social Security Number Removal Initiative (SSNRI) to protect citizens’ identity against fraud and theft by removing social security numbers from their Medicare cards, and replace them with Medicare Beneficiary Identifiers (MBI). As part of this effort, OptumServe deployed technology and program management experts and rigorous management for oversight and facilitating decision-making.
OptumServe also provided support to CMS for Quality Payment Program (QPP) initiative that replaces the Sustainable Growth Rate (SGR) formula which previously drove the reimbursement schedules for clinicians participating in Medicare. This program incentivizes providers to move from volume to quality-based payment models that improve patient outcomes and reduce costs. As part of this effort, OptumServe served as business, technical, and product management integrator to transition CMS from Waterfall to Agile and successfully create the QPP portal to accept and score performance data from the medical community.
Value-based care initiatives
As a trusted partner to CMS, OptumServe provides design and operational support and technical assistance to implement new value-based payment models. These models are designed to transform health care delivery and positively impact the health of millions of people. OptumServe also conducts independent evaluations to determine whether the models meet CMS goals. Through learning systems and collaborations, OptumServe enhances knowledge sharing and facilitates the dissemination and adoption of best practices. Some examples include:
- State Innovations Model All-Payer Operations: OptumServe provides design and operational support and technical assistance for All-Payer Model work within the Center for Medicare & Medicaid Innovation’s (CMMI) State Innovation Models Group (SIM). The purpose of these state models is to test whether transformation efforts will produce greater results when implemented in the context of an all-payer rate setting system.
- Evaluations: OptumServe conducts evaluations of several bundled payment models for CMS. Bundled payment models link the payments for physician, hospital and other health care provider services for an episode of care to incentivize all providers involved in that episode to coordinate services across all delivery settings.
- Learning Systems: OptumServe has more than a dozen learning system contracts with CMS, many of which focus on value-based purchasing, including the Maryland Primary Care Practice Model, the Comprehensive Joint Replacement Learning System, the Center for Medicare & Medicaid Innovation Cross Model Learning Network and the Home Health Value-Based Purchasing Model Technical Assistance.