OIG Medicaid Fraud, Waste, and Abuse

The Georgia Department of Community Health (DCH) is issuing this Request for Information (RFI) to identify qualified vendors capable of providing a comprehensive fraud, waste, and abuse (FWA) detection and prevention solution for the Georgia Medicaid program. DCH seeks to gather market intelligence on available technologies, methodologies, and service models that can strengthen program integrity across both its fee-for-service (FFS) and managed care delivery systems.

DCH administers Medicaid benefits to approximately 1.5 million managed care members and 591,000 fee-for-service members across Georgia, in addition to overseeing the PeachCare for Kids® program. As stewards of public funds, DCH is committed to protecting the fiscal integrity of these programs by detecting and deterring fraudulent, wasteful, and abusive billing practices among providers and recipients alike. The Office of Inspector General (OIG) currently performs program integrity functions through its Intake and Data Analytics, Review and Investigations, and Pharmacy Lock-In sub-units; however, DCH seeks to augment and modernize these capabilities through the acquisition of an advanced, technology-driven solution.

Specifically, DCH intends to procure a solution that leverages artificial intelligence, cloud-based data analytics, and subject matter expertise to: (1) detect aberrant provider billing trends and patterns of fraud, waste, and abuse in both FFS and managed care; (2) support prepayment and post-payment review functions to identify and recover improper payments; (3) verify recipient residency and eligibility to prevent duplicate enrollment across states; (4) enhance pharmacy lock-in monitoring to prevent overutilization; and (5) provide real-time access to DCH¿s internal data warehouse for rapid investigation and potential referral to law enforcement. The solution may also include a local staff augmentation component to ensure DCH maintains sufficient program integrity capacity as its Medicai