Medicaid Fraud and Abuse Detection System

The Vendor is required to provide to detect, investigate, measure and deter fraud, waste and abuse in the medicaid program.
- Provide systems and technologies capable of provider peer comparisons, case management, and reporting.
- Duties also include, but are not limited to, audits and investigations, prepayment review, overpayment recoveries, provider education, and managed care plan oversight.
- Peer comparison tool
• The tool shall use terms and terminology which precisely match those used by the state in the enterprise data warehouse (EDW).
• Terms and terminology in the tool are subject to the state’s review and approval.
• The ability to sort provider types by utilization rate, reimbursement received, procedure code billed, etc.
• The contractor is required to use state-specific provider types and specialties for peer grouping.
• The ability to reconcile provider credentialing data, including site-assessment data, with claims data
• Random or statistical sampling features
• Geographic analysis including state-specific provider type and specialty.
• Risk profiles of providers, plans, and members shall be group able for analysis by geographic regions, and geographic location shall be a searchable identifier for cases logged within the tool.
• Member-based analysis, including analytical review of member expenses.
• Benefit duplication review, for which the contractor shall engage with the administration for children and families to utilize the public assistance information reporting system (PARIS) to help identify instances of members receiving duplicate benefits in two or more states.
• Absence-of analysis (e.g. the ability to identify ambulance services without associated medical services for the same member)
• The ability for all users to “drill down” into the medicaid program data to view information on a claim or encounter basis
• The ability to automatically identify providers enrolled with the agency that have been disenrolled from other states’ medicaid programs, in particular bordering states, and/or from medicare
• The ability to detect providers which are believed to be previously penalized or disenrolled providers who have re-enrolled under a new name and/or ownership structure. (E.g. a disenrolled provider who re-enrolled under a new name and under the ownership of a spouse or family member of the original provider’s owner.)
• The ability to compare a provider against a fraud profile and/or known fraud scheme for the same type of provider
• The ability to detect providers who have worked with providers known or suspected of fraud, and/or other capabilities to detect multiparty fraud schemes
• The ability to detect possible over-prescribing
• Artificial intelligence, machine learning and/or predictive analytics features which automatically identify fraud schemes, including new and emerging ones, with low false positives
• Integration with the contractor’s workflow and case management systems to support collaboration
• Any other basis of analyzing or detecting provider-based fraud, abuse or waste such as ad-hoc reporting or queries.
- Case management system
• Provide a case management tool in which state, state designee, and contractor user’s track and resolve investigations, overpayment recovery, and manage other associated fads activity.
• Allow collaboration (e.g. allowing multiple users to open, edit or close the same case) among users
• Role-based access including:
1. Full access: (the ability to open, edit, and closes cases)
2. Partial access (the ability to view cases)
• An audit log or change history maintaining all case activity including the user who performed/entered the activity, the change(s) made, and a time/date stamp
• Allow authorized state users the ability to create logins for other users and manage role-based security
• Dashboard features providing visibility into case activities and their statuses
• The ability to query or search open and closed cases by relevant attributes (e.g. provider type, type of fraud suspected, name of provider), generate ad-hoc reports, and run queries
• The ability for authorized state users to manage all aspects of a case, including circulating among different state teams and employees, as well as reopening closed cases.
• This shall include a method to enable users to initiate the reassignment of agency leads and cases to users, which is subject to approval by administrators within the tool.
• The ability to import and export data to and from the case management solution.
• Users shall be able to import and export data from word, excel, text, csv, access, etc. users shall be able to import and export data at the individual level, case level, or in case batches.
• Users will be able to import and export financial data pertaining to recoveries.
• Workflows and status options at the state’s approval.
- Contract Period/Term: 4 years
- Pre-Proposal Conference Date: May 14, 2025
- Questions/Inquires Deadline: May 21, 2025