OIG Medicaid Fraud, Waste, and Abuse

Background

The Georgia Department of Community Health (DCH) is issuing this Request for Information (RFI) to identify qualified vendors capable of providing a comprehensive fraud, waste, and abuse (FWA) detection and prevention solution for the Georgia Medicaid program. DCH administers Medicaid benefits to approximately 1.5 million managed care members and 591,000 fee-for-service members across Georgia. Additionally, DCH oversees the PeachCare for Kids® program. As stewards of public funds, DCH is committed to protecting the fiscal integrity of these programs by detecting and deterring fraudulent, wasteful, and abusive billing practices among providers and recipients alike. The Office of Inspector General (OIG) currently performs program integrity functions through its Intake and Data Analytics, Review and Investigations, and Pharmacy Lock-In sub-units. However, DCH seeks to augment and modernize these capabilities through the acquisition of an advanced, technology-driven solution.

Work Details

DCH intends to procure a solution that leverages artificial intelligence, cloud-based data analytics, and subject matter expertise to: (1) detect aberrant provider billing trends and patterns of fraud, waste, and abuse in both FFS and managed care; (2) support prepayment and post-payment review functions to identify and recover improper payments; (3) verify recipient residency and eligibility to prevent duplicate enrollment across states; (4) enhance pharmacy lock-in monitoring to prevent overutilization; (5) provide real-time access to DCH’s internal data warehouse for rapid investigation and potential referral to law enforcement. The solution may also include a local staff augmentation component to ensure DCH maintains sufficient program integrity capacity as its Medicaid delivery models evolve.

Period of Performance

The RFI is issued solely for planning purposes; it does not constitute a commitment for future procurement or specify a period of performance.

Place of Performance

The services will be performed within the state of Georgia as part of the Medicaid program.

Bidder Requirements

Vendors must demonstrate capabilities in fraud detection technologies relevant to Medicaid programs. Specific certifications or qualifications are not detailed in the RFI.