States, safety net providers recover millions from Medicaid fraud schemes.

Innovations in Section 1115 Demonstrations

This article discusses how States have taken advantage of the flexibility afforded under section 1115 research and demonstration authority. It describes how States have used Section 1115 authority to develop innovations in outreach and enrollment, eligibility requirements, access, benefits, quality assurance, payment, safety net providers, and special needs populations. It concludes by discussi...

Changing state and federal payment policies for Medicaid disproportionate-share hospitals.

The Medicaid disproportionate-share hospital (DSH) program has been the subject of considerable policy debate throughout the 1990s, prompting Congress to revise the program three times since 1991. Using Medicaid administrative data and information obtained from twelve state case studies, we examined how the study states dealt with the federal reforms. We found a variety of state responses, rang...

Changing State And Federal Payment

The Medicaid disproportionate-share hospital (DSH) program has been the subject of considerable policy debate throughout the 1990s, prompting Congress to revise the program three times since 1991. Using Medicaid administrative data and information obtained from twelve state case studies, we examined how the study states dealt with the federal reforms. We found a variety of state responses, rang...

How are safety-net providers faring under Medicaid managed care?

Outlier-based Health Insurance Fraud Detection for U.S. Medicaid Data

Fraud, waste, and abuse in the U.S. healthcare system are estimated at $700 billion annually. Predictive analytics offers government and private payers the opportunity to identify and prevent or recover such billings. This paper proposes a data-driven method for fraud detection based on comparative research, fraud cases, and literature review. Unsupervised data mining techniques such as outlier...