Improving the Processes and Safeguards for Fraud Detection and Prevention in US Medicaid

Hoener, P.M. (2015) Improving the Processes and Safeguards for Fraud Detection and Prevention in US Medicaid.

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Abstract:This paper describes the organizational context of the fraud control setting in Medicaid, and process and technological aspects that define current state and its effectiveness. Literature and document review utilizing open coding, and process mining applied on a work system in use allow for a comprehensive holistic overview on Medicaid fraud control. Four major control systems were identified, while the fraud control process defines the control span between initial claim inception at State Medicaid Agencies, federal postpayment review and potential fraud referral. Investigating the processes and safeguards in detail along with roles and responsibilities of the parties involved, a number of limitations were identified that severely mitigate current efforts to protect the Medicaid fund from improper payments and, most significantly, fraud. A set of actions was defined to improve the processes and safeguards targeting the process, technological and organizational setting. In two interviews with experts these limitations were validated, and requirements for change and actions for de-limitations discussed. Recommendations include requiring state agencies to implement predictive analytics systems, modernize state IT architecture, and increase Manual Review during prepayment processing. In the future, without a fundamental coordinated control strategy, the Medicaid fund will remain susceptible to fraudsters.
Item Type:Essay (Master)
Faculty:EEMCS: Electrical Engineering, Mathematics and Computer Science
Subject:54 computer science, 85 business administration, organizational science
Programme:Business Information Technology MSc (60025)
Link to this item:http://purl.utwente.nl/essays/69016
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