Medicaid Fraud and Abuse Detection System

The state of Indiana is seeking a qualified vendor to provide a comprehensive Medicaid fraud and abuse detection system. This solution must offer 24/7 management and maintenance, utilizing terminology consistent with the agency’s Enterprise Data Warehouse to ensure seamless integration. The required system should support advanced analytics, including sorting provider types by utilization rates, reimbursement amounts, procedure codes billed, and more. It must accommodate Indiana-specific provider types and specialties for accurate peer grouping and offer features such as reconciliation of provider credentialing and site-assessment data with claims data, random and statistical sampling, and robust geographic analysis tailored to Indiana regions.

Additional capabilities should include member-based analyses, such as reviews of member expenses and the ability to detect service anomalies (e.g., ambulance services without related medical services). The system must allow users to drill down into claims and encounter data, identify providers disenrolled from Medicaid in bordering states or Medicare, and facilitate comprehensive risk profiling of providers, plans, and members based on geographic and case-logged data.

Vendors must also provide comprehensive user training for state and contractor personnel. Training delivery may include in-person sessions, remote instructor-led modules, and computer-based materials, with on-location training required for at least two weeks during the transition period. The exact methods and logistics of training will be determined collaboratively between the agency and the selected contractor.