Ohio Launches Additional Anti‑Fraud Initiative with
New Medicaid Data Intelligence Platform
COLUMBUS, Ohio –The Ohio Department of Medicaid (ODM) today announced the addition of a cutting‑edge fraud detection and analytics platform to enhance program integrity and protect taxpayer dollars. The nationally recognized tool, which has won an Award from the Centers for Medicare & Medicaid Services (CMS), was made possible with the approval from the Ohio Controlling Board to amend Ohio Medicaid’s existing services contract with Milliman, Inc.
“Ohio taxpayers deserve a program that is protected, accountable, and aggressively defended against fraud, and this tool helps us deliver exactly that,” said Ohio Department of Medicaid Director Scott Partika. “By advancing tools that strengthen transparency and efficiency in detecting Medicaid fraud, waste, and abuse, Ohio reinforces its commitment to protecting public resources and ensuring reliable care for the individuals who depend on these programs."
A New Era of Data‑Driven Fraud Detection
Milliman’s Healthcare Anomaly Detection Platform brings together advanced modeling, predictive analytics, and transparent risk scoring to help ODM quickly identify potential fraud, waste, and abuse. It breaks down risk in plain language, highlights provider networks that might be working together, and builds evidence packages investigators can use right away. The approach has already earned national recognition, winning CMS’s “Crushing Fraud Chili Cook‑Off” for its explainable AI.
The system surfaces potential fraud cases and provides actionable, auditable evidence. By producing a composite risk score for providers, Milliman’s tool enables program integrity teams to quickly prioritize investigations and uncover coordinated fraud networks.
Data‑Driven Action and Long‑Term Prevention
ODM stated that identifying fraud is only the latest step. The agency is preparing for the policy, operational, and enforcement changes necessary to act swiftly and decisively on high‑risk findings.
“Ohio is applying advanced, data‑rich analysis to gain a clearer and more complete view of fraud risk within Medicaid,” said Director Partika. “Provider enrollment and population management cannot be loosely managed. We need the most timely, actionable data and may need to strengthen expectations in high‑risk service areas, enforce tighter scrutiny, or make policy changes where appropriate. The long‑term goal is not just discovery—it’s prevention.”
Under the Controlling Board-approved amendment, ODM will invest $900,000 in SFY26, $431,100 from state funds and $468,900 in federal funds, to expand Milliman’s scope of work, respond to increased program demands, and implement the Milliman Healthcare Anomaly Detection Platform.
Enhancing Medicaid Fraud Prevention with LexisNexis Data Intelligence
These efforts further the state’s commitment to continuously advancing its data capabilities, including recent Controlling Board support for a new partnership with LexisNexis, which is already delivering deeper insight into identity‑based fraud risk. LexisNexis supports Ohio’s Medicaid program by running a population level identity risk assessment that analyzes provider records using physical, digital, grouping, and analytical intelligence. This includes verifying provider identity information, detecting inconsistencies, and flagging anomalies such as invalid or mismatched personal data, addresses, digital-risk signals, or records associated with deceased individuals. These checks help identify potentially fake, nonexistent, or high-risk providers who may be attempting to bill Medicaid fraudulently.
Under the state’s Data Sharing and Confidentiality Agreement, LexisNexis receives provider data from the Ohio Department of Medicaid specifically to perform this multi‑phase Spectrum Risk Analysis. This analysis is designed to reduce fraud, waste, and abuse, by detecting improper‑payment risk and uncovering providers whose identities can’t be validated. Strict HIPAA‑compliant safeguards ensure that the data is used only for fraud‑detection and program‑integrity purposes.
Together, Milliman’s advanced analytics and LexisNexis’s identity‑verification intelligence give Ohio a stronger, more coordinated defense against Medicaid fraud. These investments position the state to move faster, act with greater precision, and prevent losses sooner. By combining advanced technology with strengthened oversight and enforcement, Ohio is establishing a more resilient program‑integrity system that protects public funds and keeps Medicaid dependable for the people who rely on it.
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