Harnessing the Power of Data Analytics for Medicaid Provider Claims


After the session at the IDEA User Conference on using data analytics to analyze purchase card usage, I had the opportunity to attend a session on how data analytics can be used to perform analysis on Medicaid provider claims data.


Jennifer Blanchard is a certified fraud examiner (CFE) for the Ohio Auditor of State’s office, and she has a big job. Her mandate is to ensure that providers of healthcare services reimbursed with Ohio’s Medicaid dollars are in compliance with applicable rules and regulations. Medicaid accounts for more than 35% of the state’s budget, and there are more than 83,000 active Medicaid providers in Ohio—that makes for a lot of data to review.


Medicaid-related fraud is a pressing issue in Ohio. According to Blanchard, ensuring that state taxpayer dollars are spent efficiently meant that performing more audits and verifying appropriate expenditure of public funds by analyzing all transactional data was in the public’s best interest.


Blanchard’s office audits a variety of provider types, including: 


  • Durable medical equipment
  • Emergency response
  • Home health
  • Transportation, such as ambulances and ambulettes
  • Physician
  • Mental health


They found that overpayments occurred most often in transportation services and home health. In fact, 95% of total overpayments for the last five years were found in these two departments. For transportation providers, Blanchard looks for red flags such as:


  • Attendant codes not being billed correctly
  • Large number of U6 modifiers from transportation providers
  • Billings for trips not actually provided
  • Number of transports unreasonable compared to known number of vehicles
  • Transports billed higher than average of a period of time
  • Recipients with more than three transports per day
  • Transports more than 50 miles


Blanchard has also built standard data analysis tests for home health providers. The end result? Not only has the team identified overpayments, they’ve also increased the number of audits released per year tenfold compared to levels from the previous year. Those are quantifiable and measurable results that any data analytics and audit team can take to management.


Contact us to learn more about how CaseWare Analytics products can be used for healthcare.



About Anu Sood:

Anu Sood is the Director of Product and Corporate Marketing at CaseWare Analytics and is responsible for the company’s global marketing strategy. Prior to CaseWare Analytics, Anu worked in various roles in the high-tech industry and her accomplishments range from writing software for telephone switches to launching a new global satellite communication service. Anu has extensive experience in strategic marketing, corporate communications, demand generation, content marketing, product management, product marketing and technology development. 

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