AI, advanced analytics, Medicaid fraud take center stage at National Conference for Healthcare Payers

PORT WASHINGTON, N.Y. -- In the evolving battle to safeguard the integrity of its Medicaid program, early this month at NAMPI 2023, the District of Columbia Department of Health Care Finance Division of Program Integrity showcased its strategic collaboration with Sandata Technologies, the pioneering force in the homecare industry, that proactively combats fraud, waste, and abuse (FWA) in Medicaid. Representatives from the two organizations appeared on a panel together at the conference to discuss how they partner to limit FWA.

With a keen eye on protecting taxpayer resources, the District of Columbia was a lighthouse client of Sandata Fraud Alert, a cutting-edge FWA program. Utilizing advanced data analytics and Artificial Intelligence (AI), Sandata Fraud Alert proactively mines Electronic Visit Verification (EVV) and other homecare data to swiftly identify suspected FWA cases in near real-time.

A Proactive Approach to Fraud Detection

Unlike traditional post-payment investigations and recovery models, Sandata Fraud Alert utilizes near real-time AI models to proactively identify patterns and irregularities suggestive of fraud or abuse. Suspicious activities, such as a caregiver serving two clients simultaneously; two caregivers with the same client at the same time providing the same service; or a caregiver being located at a different place than the client during service, are swiftly flagged for further investigation, typically within hours of the visit. This cutting-edge approach allows states and Managed Care Organizations (MCOs) to intervene before claims are paid, to significantly reduce fraudulent claims and minimize the need for subsequent litigation and recovery expenses.

"With an estimated cost of $2B*in home personal care services fraud alone, Medicaid fraud is an issue for everyone,” said Brian Lawson, VP, Government & MCO, Sandata. “Many of these beneficiaries are fragile members who because of fraud are not getting the care they need and deserve, and end up in more expensive institutional care settings, such as the ER. With Sandata Fraud Alert, we can spot fraud in near real time and act right away, without having to wait for the claim to come in.”

Taking a Stand Against Medicaid Fraud

“Sandata is committed to making very significant investments into reshaping the future of homecare,” stated Emmet O’Gara, CEO of Sandata. “This includes the entire homecare ecosystem – payers, agencies and their caregivers, Medicaid beneficiaries, and individual taxpayers – the majority of whom do the right things and are negatively impacted by others’ fraudulent activity. We use our vast industry experience to leverage AI and other sophisticated technologies to help proactively solve this, and other industry challenges.”

“Proactivity is a word that stands out when I think about the real value here,” said Kevin O’Donnell, Director, District of Columbia Department of Health Care Finance, Division of Program Integrity. “With Sandata Fraud Alert, we are catching potential fraud early in the process by harnessing advanced technologies to ensure program sustainability and efficiency. We are looking forward to continued collaboration with Sandata to combat this important issue.”