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FWA Insights & New Approach: State of Missouri, Medicaid Audit and Compliance Team


Steven Goldberg, MD, MBA

In an era of rising healthcare costs, administrators and decision-makers actively seek ways to reduce costs. Prevention and detection of fraud, waste, and abuse (FWA) is one key strategy to yield considerable cost savings in healthcare. While government agencies have programs and tools to detect, prevent, and reduce improper healthcare spending, existing tools and processes have been tedious, time-consuming, and insufficient. This case report describes the State of Missouri’s Medicaid Audit and Compliance implementation of a new tool (FWAFinder© by Alivia Analytics) to identify and reduce improper healthcare spending. Results show that after one year, more than 15k actionable leads were identified, 98 unique FWA scenarios were reviewed for risk, and more Medicaid dollars were recovered in a single month than the yearly cost of the program (extrapolated ROI of $12: $1). Thus, this case report demonstrates encouraging evidence and opportunity for analytics solutions to aid in the engagement of FWA in the healthcare system.

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