Artificial intelligence solutions considered to tackle Medicaid fraud
House Republicans’ plan to address Medicaid fraud earned praise on Tuesday, but proponents still believe further changes are needed.
Members of the House Medicaid Committee were provided that assessment at the third hearing of the plan being fast-tracked by legislative leadership (HB 795.)
Many lawmakers also focused on how artificial intelligence can help officials go through data and identify trends, perhaps finding solutions in a more efficient manner.
To do that, though, Ohio Council for Home Care & Hospice Executive Director Lisa Von Lehmden said humans must still be engaged in the process. She told Rep. Rachel Baker, D-Cincinnati, that a subcommittee should be formed to review whatever suggestions an AI model makes.
Sabrina Donley, AI practice leader of CybrCastle, added that AI can help identify known Medicaid fraudsters, noting prior work the Mason-based company has done with the U.S. Department of Homeland Security and Department of Defense.
Through generative AI, she said investigators can identify the most problematic bad actors quicker and in greater detail.
At the same time, Donley said it is “not a silver bullet.”
“AI should not replace investigators. AI should augment investigators,” she told the panel. “The goal is to prioritize where human judgment is needed most. As investigators review findings, the system learns from those decisions. False positives can be reduced.”
Asked by Rep. Kellie Deeter, R-Norwalk, what is the proper human oversight, Donley said humans should take a look at what is already known and then test it against the AI model.
AI also learns through feedback from users, which Donley said means “keeping the human in the loop is important.”
Rep. Derrick Hall, D-Akron, also asked how expensive and how long it would take to implement an AI-powered analysis of the program. CybrCastle President and CEO Steve Dong said it would likely take a six-figure investment and take roughly three to six months to fully study the program.
The state should also not exactly replicate how the U.S. Department of Government Efficiency attempted to tackle fraud in Washington, Donley told Chair Rep. Jennifer Gross, R-West Chester.
“I think what’s important for Ohio is to use the data but make sure that the right people are involved, the right processes are involved and the right governance,” she said.
A week earlier, the committee approved a substitute that in part increased penalties for Medicaid fraud; authorized the Department of Medicaid to impose payment suspensions and investigations for suspicious increases in claims; and permitted the Department of Insurance to create an all-payer claims database.
The measure is expected to land new changes during another hearing set for 3 p.m. Wednesday.
Members of OCHCH said they appreciated the intent of the bill, which they said would make the program more transparent and enhance fraud detection while expanding electronic visit verification standards.
Still, Von Lehmden said reforms need to be “implemented consistently across all Medicaid-funded care delivery models.”
She recommended several amendments pertaining to EVV payments related to GPS verification, provider suspension, fraud analytics and waiver oversight.
“Each amendment addresses a different gap in the current version of the bill, but they share a common concern: that enforcement consequences should be grounded in evidence, not in system errors, algorithmic flags, or administrative process failures,” Von Lehmden told the panel.
Sponsor Rep. Josh Williams, R-Sylvania Twp. said there are three types of home care providers, with most fraud coming from independent and self-directed providers rather than agency providers.
Asked why there was that discrepancy, Von Lehmden said agency providers have to be accredited and receive a Medicaid number while independent and self-directed providers are not held to that same standard.
“The level of oversight and whatnot that takes place to be able to get to self-directed care is minimal as compared to what we have to do as agencies, which is why we're saying if a patient wants to choose their provider, by all means, go ahead,” she said. “But why can't that relationship live within an agency where we are providing that extra level of oversight as owner operators?”
Donovan O’Neil, state director with Americans for Prosperity-Ohio, said the state’s Medicaid program spending has grown from $17 billion in Fiscal Year 2016 to $22.3 billion in the current fiscal year.
“We have long opposed Medicaid expansion because we understood that a program expanded without the accountability infrastructure to match was a program set up to fail the people, most importantly, it was meant to serve,” he said.
“The fraud crisis playing out now is exactly what we cautioned against.”
Rep. Ron Ferguson, R-Wintersville, noted that lawmakers moved to eliminate the Joint Medicaid Oversight Committee in the budget last year (
HB 96.)
Asked if that move could impact the state’s ability to provide robust oversight, O’Neil replied that budget also empowered legislative committees to take up that work, adding that “we are seeing that through this panel.”
House Speaker Matt Huffman, R-Lima, was similarly asked about the elimination of JMOC last month when Republican gubernatorial candidate Vivek Ramaswamy unveiled his plan to combat Medicaid fraud in the state.
O’Neil also supported language in the bill regarding EVV, which “requires GPS-enabled clock-in/clock-out for all in home care services and mandates that each claim be supported by a validated EVV record as a condition of payment.”
Rep. Anita Somani, D-Columbus, asked if he had any privacy concerns with the usage of GPS, to which he replied that while he understood that sentiment, those home care providers perform a service that requires oversight.
Rep. Jason Stephens, R-Kitts Hill, said the budget transparency language in HB795.
is a vital piece of the equation in determining how those dollars are spent.
Asked if a system similar to Ohio Checkbook could further shed light on Medicaid spending, Kimberly King with Home Care Network, Inc. told Stephens it could be, with a caveat.
“That's not going to help nearly as much as understanding what services are actually provided during the time period that they're in the home,” she replied. “So, you're going to have to be able to balance that to some degree because people don't necessarily understand how our businesses are run.”
Mehek Cooke, an attorney and Fox News contributor, said she spent months investigating allegations regarding the state’s home- and community-based services waiver programs.
She said what she determined was that unqualified care providers and other home care facilities were bringing in millions while not being present at the facility.
Rep. Crystal Lett, who has a child who receives home-based care, said it was interesting that Cooke went to the office as most home care providers are in the community and not in the office.
The Columbus Democrat said it was not a reasonable expectation for them to be there. Cooke replied that she does not expect them to be in the office full-time but said enough people have to be on-site for it to be functional.
Others like Medicaid Director Scott Partika and Ben Karrasch, section chief of the Health Care Fraud Section and director of the Medicaid Fraud Control Unit within the AG’s office, also previously requested additional changes.
State Auditor Keith Faber; Senate Minority Leader Nickie Antonio, D-Lakewood; and Rep. Mike Dovilla, R-Berea, meanwhile, signaled that they will be testifying before the U.S. House of Representatives of Wednesday regarding the state’s Medicaid waiver program.