Illinois Predictive Modeling System Abstract
In 2007, 27 states received Medicaid Transformation Grants under Section 6081 of the Deficit Reduction Act of 2005. The grants were rewarded to states that proposed innovative methods which in the end of the two years are designed to produce better health outcomes at lower cost.
The Center for Health Transformation is highlighting states that have received these Medicaid Transformation Grants, and will be following their progress for the next two years. In order for key decisionmakers and industry leaders from around the country to learn from others’ successes, it is our intention to provide this resource in order to showcase innovative practices from across the nation. In the future, this site will be interactive, allowing program directors to submit updates and comments regarding their program.
The Illinois Department of Healthcare and Family Services (HFS) seeks to transform its Medicaid program integrity efforts by developing a predictive modeling system. The system will leverage Illinois’ historical data from previous fraud and abuse cases in order to develop well-honed fraud predictors. This system will go beyond typical surveillance systems currently in use by utilizing the insights from existing integrity review results to generate future case referrals and enable HFS to rapidly act to improve patient care, prevent fraud and lessen the burden to legitimate providers. The goal of the project is to build a sustainable predictive modeling system that functions beyond the two-year grant period.
The two-year budget for this project is $4.85 million. The funding will enable HFS to establish a rich analytical dataset and build an infrastructure that supports far-reaching data analyses and predictive modeling campaigns. During the funding period, Illinois will use this capability to improve care for asthmatic patients and identify collusion between psychotherapy and non-emergency transportation providers. The grant will also provide for an innovative data distribution system to share the results with stakeholders. This grant project will establish significant, far-reaching capabilities for Illinois that can be migrated to other state Medicaid programs during the post-funding period.
The overall effectiveness and efficiency of the State’s Medicaid program will be improved by addressing new target areas with actionable analytical results and prepayment strategies that will enable Illinois to prevent or reduce the incidence of treatment or payment errors. The system will support initiatives and enforcement efforts to:
- Manage and educate Medicaid recipients who over-utilize Medicaid services
- Target and subsequently sanction providers who are rendering a substandard level of care to the Medicaid recipient population
- Partner with state agencies responsible for health care oversight and delivery
- Reduce expenditures by rapidly identifying groups of providers involved in organized fraudulent deceptive practices
- Implement preventative measures, e.g., prepayment surveillance routines
The predictive modeling system holds significant promise to transform Illinois’ approach to preventing and detecting fraud and abuse in the Medicaid program. Ultimately, the outcomes of this system will:
- Improve the quality of care rendered to the Medicaid recipient population
- Identify emerging provider fraud schemes rapidly, accurately and efficiently
- Focus on the dynamic environment of the health care delivery system and the latest treatment schemes
- Focus on problem areas identified through federal and other state medical program integrity initiatives
- Reduce expenditures and increase overpayment recoupments
