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JUNE, 2022

Medicaid Auditing as a Service (MAaaS)

White Paper by Dr Roger Oren, PhD PMP

Ensuring Program Integrity

Seeing that federal funds are spent according to direction, the Office of Inspector General (OIG) within the Department of Health and Human Services (HHS) conducts evaluations, inspections and audits of HHS programs, grantees and contractors entrusted to deliver healthcare for our citizens. The latter effort, audits, “help reduce waste, abuse and mismanagement and promote the economy, efficiency, and effectiveness of programs and operations throughout HHS” (Office of Inspector General, 2022, p. 2). Auditing the Medicaid program finds issues which are then resolved through recovery, criminal or civil actions.

Due to the size of the program, deviations are found, some quite large. The OIG, during the reporting period of October 1, 2021 through to March 31, 2022, highlights 320 criminal actions with $1.44 billion in expected investigative recoveries (Office of Inspector General, 2022, p. 5). In addition to these items the OIG determined that $1.6 billion were questionable costs, or “costs not supported by adequate documentation, or the expenditure of funds where the intended purpose is unnecessary or unreasonable” (Office of Inspector General, 2022, p. 5).
The reader should ask if this situation can be corrected, and if so how. The solution, is rather simple, it is to audit data from their own systems, using teams knowledgeable in data science and data analytics.

Organizations need to move from a reactive process to a pro-active process.

Medicaid Auditing as a Service (MAaaS)

Find your program integrity problems before the OIG team, and correct those deficiencies to ensure the following:

  • Reduction in Program Recovery funds sent to HHS
  • Reduced funds leaking into criminal enterprises
  • Increase documentation on costs identified as questionable

Our team has the experience in Medicaid programs, over many years, many situations, and many States to help aid and guide your program toward a proactive process. We understand Medicaid deeply, and can help in auditing, continuous process improvement, project management, and data science.

  • Our team has over 140 years of experience in Medicaid
  • Our team can look at X12 transactions for errors and omissions
  • Our team has Data Engineering and Data Science expertise
emrts team member

Data Science and Engineering for Today

Our scientists and analysts can look deeply into the data, using methods to develop insight into your data. On the Machine Learning front, through the use of a DevML process, to extract and cleanse the data, transform and load it into machine learning models to produce visuals and statistics to uncover meaning in your data.

Visualization samples are show in figure 1 & figure 2.
graphic illustrating the case clusters

Interested in engaging our team? We provide Proactive Auditing services to keep clients in compliance with Federal regulations.

Contact us for a quote on our base services and claims-for-fee auditing.

Dr. Oren has experience managing diverse teams in multi-million dollar efforts creating mission-critical applications, within domestic and international settings. He consults in a variety of industries who have regulatory, organizational, technology and cultural imperatives requiring organizational, program, process and technology solutions. As an Academic, Dr. Oren teaches at several Universities, and publishes articles for the project management, technology and organizational reader in academic and practitioner media.