NAMPI 2024: Drug Compounding and AI on the Rise

It’s been two years since I’ve attended the National Association for Medicaid Program Integrity Conference. This year the conference was held in Hollywood South, the Crescent City, the Big Easy, also known as N’awlins. Two years ago, I attended NAMPI as a newbie, sharing the stage with my seasoned colleagues. This year, I visited NAMPI a little more knowledgeable but still impressed by the tenacity and dedication program integrity professionals bring to deter fraud and remove waste from our health care system.

In case you need a refresher, NAMPI’s mission is to safeguard the fiscal, operational, and program integrity of Medicaid. Program Integrity (PI) professionals descend upon the NAMPI conference and share techniques, technology, and information used for finding and dissuading Medicaid fraudsters and preventing wasteful spending.

This Year’s NAMPI Conference

Just like last time, federal and state PI professionals came together to share some of the latest schemes shady providers use to “get over.” Two years ago, yours truly and some of Qlarant’s brightest minds highlighted tricks providers use to overbill and share hospice care recipients. This year, one spotlight was on the notable industry concern of drug compounding.

The popularity of Ozempic, Wegovy, and other weight loss drugs has led to high costs, and patients are resorting to high stakes efforts to acquire them. Demand for these treatments has led to an increase in companies mixing the effective ingredients, or compounds, of these drugs.

Drug compounding provides a potentially lower cost and higher risk alternative to buying the name brand. In some cases, providers are improperly billing for compounded drugs. In other cases, these drugs can be dangerous due to less sanitary conditions where compounding takes place, or improper dosage mixes of specific compounds. In all of these cases, Medicaid PI professionals are on the lookout— doing all they can to protect patients from harm.

Data, Data, Data Everywhere

A data trail forms the path to snuff out fraud. Nearly every session at this year’s NAMPI conference featured analytical approaches to sniffing out fraud. Two years ago, GPT-3 entered the world stage after NAMPI 2022. Then, AI was mentioned but not a primary focus. This year, data is everywhere, and AI is presented as THE solution for making sense of it all. However, data and AI only make up part of the equation. Interpreting data is still a challenge best performed by humans.

With advanced tooling and a year of Large Language Models (LLMs) in the news, data and AI are promising tools that can be used for finding fraud. However, fraudsters exhibit different behaviors across provider domains, and different states have different regulatory levers to maintain compliance. At Qlarant, Artificial Intelligence + Human Intelligence (AI+HI) is used to create better outcomes. The key to successful outcomes is combining the right tools, techniques, and talent.

We all know AI is here to stay, and AI use is going to increase in our fraud and waste prevention efforts. The key to successful implementations will be how AI can be used to support our decision making. That requires more than processing data. It requires the knowledge, experience, and intuition of PI professionals that we have here at Qlarant.