Sunday, November 20, 2011

RFI Addresses Medicaid Fraud

The Texas Health and Human Services Commission (HHSC) released RFI (No. 529-12-0056) “Pre-Payment Review of Claims and Other Strategies to Reduce Medicaid Fraud”. Feedback is needed by December 10, 2011 from capable sources to provide leading cutting-edge technology capabilities for predictive modeling/management software as well provide claim review services and workflow management tools.

HHSC is trying to determine what products exist in the marketplace that will help eliminate pre-payment fraud. HHSC also wants to know about products that are not ready and when the product release is planned. HHSC may use the information contained in the RFIs received to develop a future procurement.

HHSC wants more information on systems that can:

• Handle high volume of transactions
• Be integrated into the existing Medicaid claims flow with minimal effort, time, and cost
• Provide a rapid, real-time, or near real-time solution with large data storage available to provide for data mining and pooling capabilities
• Analyze Medicaid managed care encounter data as HHSC transitions from FFS to a MCO delivery system
• Permit modifications to the software in a rapid and timely manner
• Provide a change control process to enable quick changes to be made to changing patterns of behavior
• Mark each flagged claim with a Medicaid-defined reason code to help the human reviewer understand the reason the claim is potentially improper and recommend an action
• Allow HHSC visibility into data analysis so that patterns of excessive usage, unusual patterns, are identified, scored, and implemented rapidly
• Provide views for all provider and patient activities across all federal health program payers
• Provide workflow management and workstation tools that can systematically present scores, reason codes, and treatment actions

Go to to view the RFI. For more information, email Steve R. Bailey at or call (512) 206-4653.