Case Study: Illinois Department of Healthcare and Family Services halts Medicaid fraud and prevents overpayments with SAS Analytics

State of Illinois identifies and tackles claims fraud with SAS® Analytics

The Illinois Inspector General’s Department of Healthcare and Family Services needed a more sophisticated way to detect Medicaid claims fraud than traditional exception-processing. The agency wanted to leverage historical integrity audits and social-network relationships to spot fraud at the transaction and patient level, identify colluding providers and uncover schemes run by criminal networks.

Using SAS Analytics and SAS Enterprise Miner, the agency built a fraud platform that trains predictors on past abuse cases, scores providers with a provider-risk index, and applies dynamic network association routines to reveal suspicious relationships. The solution identified overpayments, prevented further improper payments, uncovered criminal-network fraud, and significantly reduced model-creation time from weeks to hours while improving accuracy and reporting efficiency.

Illinois Department of Healthcare and Family Services

Weishin Wang

Inspector General’s Department of Healthcare and Family Services