Earlier this month I spent a few days at this year’s National Association for Medicaid Program Integrity (NAMPI) conference. After an in-person break due to COVID, fraud investigators and program integrity professionals gathered for their annual conference in Baltimore. As a first timer, there was a lot to see and a lot to learn among the nation’s top FWA and program integrity professionals.
NAMPI safeguards the fiscal, operational, and program integrity of Medicaid. The group shares information, techniques, and methods for reducing and halting fraudulent and wasteful spending of Medicaid resources and recovering funds fraudulently paid to Medicaid providers. NAMPI’s FWA investigators, subject matter experts, analysts, and others work hard to recover funds paid to providers practicing fraud. At Qlarant, we assist our NAMPI peers in state agencies by providing operational subject matter expertise, analytics, and software.
Overview of Sessions
State agency and vendor sessions covered the gamut across techniques and technologies. Today’s FWA analysts are using artificial intelligence (AI) and machine learning (ML) to identify patterns across payment transactions as well as other aberrant behaviors. Among the many booths were companies providing new, real-time services utilizing AI/ML to flag fraudulent providers. Analytics companies promoted new ways of generating informatics from multiple data integration points. Others utilized their expertise in cybersecurity forensics to provide clever ways of deep diving into data to uncover the most critical aspects of fraud data. At NAMPI, Qlarant showcased unified solutions connecting all of the dots between real-time AI/ML, state data systems, and national databases. Unified systems, like RIViR, bring everything together to pipeline fraud identification, visualization, and resolution.
FWA detection and prosecution is fraught with challenges. Those challenges have been compounded after a global pandemic that has strained state budgets. “Do more with less,” becomes a rallying cry for those determined to make the bad guys pay what they owe. The overarching theme across all of the sessions was maximizing constrained resources to deliver the maximum return. Essentially, increasing the recovery rate and value of fraudulent Medicaid billings.
The State of Texas has boosted their effectiveness by emphasizing training and process improvement. Their state, like many others, has an overtaxed legal team and they’ve relied on a system that streamlines case identification and priority. Missouri demonstrated how refining analytics can bring efficiency gains.
RIViR and Hospice Fraud
We contributed Hospice FWA detection to this year’s conference and demonstrated a new, RIViR Hospice Fraud solution. Our live session and panel illustrated how collaboration, advanced techniques, and technology can deliver significant results. In one of the few sessions that dove into the nitty gritty, our session leader—Otis Washington—explained how indicators across five key areas can identify providers exhibiting fraudulent behavior.
He explained how data collected from multiple sources can be used to build a case against providers. In specific cases, one behavior or a series of specific behaviors may not be enough to demonstrate fraud. However, a combination of information, including claims and medical records and statistical data, can help FWA professionals find the bad guys.
In a magical moment, NAMPI attendees caught a glimpse of how Qlarant leads in this area. As questions were coming in after Otis’ presentation, one specific question was a head-scratcher. The question was deep in the details of medical records and billing with no straightforward answer. Qlarant medical reviewers, clinicians, and SMEs who sat in as cheerleaders put their thinking caps on. Each of our people contributed a bit of their expertise to fully answer the attendee’s question.
That’s what we do. We work together. Our commitment to finding fraud and recovering the “People’s Money” is core to our values.
I may sound over dramatic, but I was dazzled and amazed by my first NAMPI Conference. Day-in and day-out, I’m a tech guy who works with these professionals and I often have an abstract view of their challenges. I’m typically asked to help them get results versus being in the middle of investigations.
NAMPI opened my eyes and made the job more real. I had an opportunity to speak in person to many people who I’ve spoken with on the phone or have used our software. I met seasoned professionals who had some amazing stories to tell. I also learned how the landscape is constantly shifting, and we must remain vigilant.
Fraudsters are bold. They’re always willing to try a new scam, and that keeps us on our toes. The only way to bring these fraudsters to justice is through collaboration.
That’s why we built RIViR.
Subject matter experts know the policies and understand behaviors. Analysts know data and structure to bring meaning to numbers. Tech guys like myself provide technology that empowers SMEs and analysts to deliver information to investigators that they need to find the bad guys and bring them justice.
NAMPI brings the FWA and program integrity (PI) community together. It is a place for professionals to share insights and techniques that work for them. It even provides a forum for companies like Qlarant to show how they can support their mission.
For every new scam or scheme fraudsters try, companies like Qlarant are here, empowering FWA and PI professionals with tools to make the bad guys pay.