OIG Medicaid Fraud, Waste, and Abuse

The Georgia Department of Community Health (DCH) is seeking a comprehensive fraud, waste, and abuse (FWA) detection and prevention solution for the Georgia Medicaid program. The solution should leverage artificial intelligence, cloud-based data analytics, and subject matter expertise to detect aberrant provider billing trends and patterns of fraud, waste, and abuse. The key features of the solution include: • Detecting aberrant provider billing trends and patterns of fraud, waste, and abuse in both fee-for-service and managed care • Supporting prepayment and post-payment review functions to identify and recover improper payments • Verifying recipient residency and eligibility to prevent duplicate enrollment across states • Enhancing pharmacy lock-in monitoring to prevent overutilization • Providing real-time access to DCH's internal data warehouse for rapid investigation and potential referral to law enforcement