Pennsylvania’s Department of Human Services (DHS), which administers the state’s Medicaid program, is seeking information from vendors that offer data mining and predictive analytics that might help the state monitor Medicaid and other payments.
Among the challenges such vendors might address in their responses, as stated in the RFI, are:
- Identifying claim review strategies that efficiently and proactively prevent or address potential errors (e.g., prepayment edit specifications or parameters).
Providing mechanisms to investigate patterns that may indicate abuse of services by clients.
- Producing innovative views of utilization or billing patterns that illuminate potential errors.
Maximizing recoveries by identifying high volume or high cost services that are widely over utilized.
- Identifying areas of potential errors (e.g., services which may be non-covered or not correctly coded) that poses the greatest risk or vulnerability.
Establishing baseline data to enable DHS to dynamically recognize unusual trends, changes in utilization over time, or schemes to inappropriately maximize reimbursement. Adapting systems, rules, and algorithms on an ad hoc basis in order to be responsive to emerging trends, patterns, and issues as they are identified.
- Clearly distinguishing which applications are standardized as part of the product package and which applications will need to be purchased as a system enhancement.
- Establishing baseline data and recommendations to improve the client experience related to access to services and the quality of the services received.
The call for vendors is a request for information (RFI) and not a request for proposals (RFP) but it appears likely that the state will issue an RFP after it has had an opportunity to review the information submitted to it.
RFI submissions are due on November 9. See the RFI document here.