Fraud Analytics team building new tools to combat fraud in Texas

To maximize efficiencies in OIG operations, the agency's Fraud Analytics team develops algorithms that leverage data analytics to fight fraud, waste and abuse in Texas Medicaid delivery. During the second quarter of fiscal year 2024, Fraud Analytics received 182 data requests, completing 163 through the execution of 97 algorithms.

The Fraud Analytics team also spent the last quarter developing algorithm audits in coordination with the OIG Audit team. These reviews sampled claims from various providers using the algorithm to flag irregular billing behaviors. The team then adjusted the program after comparing medical records to improve accuracy in recognizing potential fraud, waste and abuse.

In tandem with the algorithm audits project, Fraud Analytics is developing dashboards for each medical, dental and pharmacy provider that will allow investigators to take a comprehensive look at billing, rendering, referring and prescription trends. This dashboard will also provide peer comparison data, allowing a more efficient evaluation of whether the provider's submissions should be flagged for irregular behavior.

The OIG continues to leverage technology to find new methods to protect the approximately $46 billion spent on Texas health and human services each year.