Program Integrity’s Changing Workforce Sparks New Approaches to Policy Knowledge

State agencies apply technology to enable fraud, waste and abuse investigators to spend less time on manual policy research

By | 2 minute read | November 11, 2019

A recent study estimated the annual cost of waste in the United States healthcare system to range between USD 760 billion to USD 935 billion.1 Government professionals dedicated to finding cases of fraud, waste, and abuse in Medicaid are on the front lines of working toward eliminating unnecessary costs in healthcare.

To do their jobs effectively, these state agency employees must have a working knowledge of the policies and codes that govern the field of Medicaid payments. They must know, for example, where to find provider and member eligibility criteria, reimbursement rules, prior authorization requirements and much more.

Some of this information may be electronically available, but it is typically data held within hundreds, if not thousands of documents. Because of the complexity and volume of information, it is an advantage to have experienced team members who know where to look.

Turnover takes its toll

Unfortunately, state agencies are among employers that are seeing higher rates of turnover as Baby Boomers have begun to retire, taking their expertise with them. For instance, public agencies in the State of Texas experienced a turnover rate of 18.6% in 2017, which was the highest turnover rate of the past five fiscal years.2

In my experience, many clients I work with have had a turnover in their unit within the last year. A mix of people is coming into the field of program integrity to fill those vacancies. They are data scientists, clinicians, policy experts, former law-enforcement professionals, and economists. They may or may not have the depth of knowledge about policies as their predecessors. As varied as their backgrounds are, they often share a common sense of mission: to protect patients and act in the public’s best interest.

I have found that program integrity professionals are often eager to dive into claims work, go on-site visits and use their skills to identify and address cases of fraud, waste, and abuse. But, if they don’t have a strong knowledge base about where to find applicable policies and codes, they may spend more time manually searching documents than they would like and may not have the background to see the connections needed to uncover the additional guidance needed to fight evolving fraud schemes.

How agencies are applying technology to enhance program integrity

Government agencies can apply technology to make it faster and easier to find this information from many different types of unstructured data and make the connection – from policy documents to medical records and case notes. Natural language processing (NLP), augmented intelligence (AI) and machine learning can help people conduct comprehensive, relevant searches.

Think about this through the eyes of a policy investigator who searches for hours on end through various data sources or policy updates to combat fraud. By applying technology to this manual process, policies can be surfaced much faster, allowing them to tackle more cases and recover payments with less time and frustration.

Aiding program integrity searches is just one use case; these technologies can help government professionals pull useful knowledge from reams of information to help combat fraud, waste, and abuse in other areas, too.



1 Humana Inc, etc. Waste in the US Health Care System: Estimated Costs and Potential for Savings. 2019 Oct 7.

2 Texas State Auditor’s Office, An Annual Report on Classified Employee Turnover for Fiscal Year 2017.

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