October 24, 2019

The OIG has taken an increasingly data-driven approach to fighting wrongdoing in Medicaid delivery. Using data analytics helps us increase the detection of fraud, waste, and abuse by assessing billing trends and patterns of providers, clients and retailers participating in HHS programs.

Experienced staff at the OIG have developed algorithms and data analysis processes to pinpoint areas where fraud may be occurring. After focusing attention on a particular provider or geographic region, the OIG then can deploy investigators and experts to corroborate findings from the data.

Data analysis is at the heart of the Fraud Detection Operation (FDO), helping to discover and assess anomalies in provider billing patterns. Providers are flagged for a closer look to determine whether their outlier status may be due to fraud, waste or abuse. Quarterly FDOs conducted by Medicaid Program Integrity (MPI) in fiscal year 2019 included examinations of chemical dependency, behavioral health, and dental providers. With each event, Data and Technology (DAT) provided MPI with analysis to help select providers identified as outliers from their peers. MPI investigators collected records from the providers, interviewed staff and contacted clients where Medicaid had paid for services. OIG FDOs resulted in multiple cases opened for identified program violations.

The OIG utilizes data analysis to not only launch audits, inspections and investigations of specific providers, but also to proactively educate providers about how to prevent fraud, waste and abuse from happening in the first place. Increasing the breadth and depth of analysis to inform decisions leads to greater protection of patients and the entire integrity of Medicaid service delivery.

You can read more about the OIG’s work with data analytics in our latest quarterly report: https://tinyurl.com/y5xeotja