The Department of Health Care Services intends to select OnCore Consulting of Folsom, Calif., as its contractor for the Medi-Cal Program Integrity Data Analytics (MPIDA) program, according to state documents.
The "notice of intent to award" was publicly released Wednesday.
"The purpose of the MPIDA program is to detect and link fraud schemes in the Medi-Cal environment. It is expected that a successful contractor will produce reports identifying suspicious cases in order to create an infrastructure for use by DHCS investigators so the Department can more readily identify providers which should be suspended or prosecuted," the department says.
The contract is capped at a maximum of $10 million per year and a duration of up to five years, according to the bid RFP, which was released in August 2015.
The potential savings in this area is significant. DHCS says a study of payment errors in 2011 estimated that more than 6 percent of payments were possibly in error, whether because of human error or due to fraud activity. The study projected $1.25 billion of payments that were in error or made fraudulently.
The contractor will use predictive modeling techniques and create a “data mart,” build quarterly reports, and install and maintain all software, hardware and the network.
As part of the bidding process last fall, DHCS provided more data about the volume of claims:
“For 2014 we had about 310 million claims header records (170 million are managed care encounters, 115 million various FFS claims and 25 million dental), 450 million claim detail records (each claims header record has one or more detailed records), 50 million denied records. The current beneficiary file has 66 million records, the current monthly eligibility file has 1.2 billion records and the current provider file has over 700,000 records, less than half of which may currently be active.”
The Department of Health Care Services selected OnCore consulting from seven scored bids.
OnCore is a certified Small Business Enterprise, according to the company's website. Oncore partnered with Pondera Solutions of Gold River, Calif., and LexisNexis Special Services Inc. on the bid.
