Automated Anti-Fraud Saves Millions in Massachusetts

By Jeff Valentine, executive account manager for Government Healthcare Solutions at Xerox

(From the editor: This article was excerpted from Health Focus, a digital magazine that is published by Xerox Government Healthcare Solutions. Health Focus  presents a vast array of information that affects the healthcare industry. Read the complete article.)

Public assistance programs are a lifeline for eligible beneficiaries, but they are also a major target for fraud. When ineligible applicants receive benefits, they drain resources from the people who need them most. The Commonwealth of Massachusetts got in front of the problem with an initiative that automated program integrity.

It has already saved several million dollars.

Federal and state audits discovered that the Commonwealth’s Department of Transitional Assistance (DTA) had made inappropriate benefit payments to people who did not qualify. Some had unreported income; others were not legally Massachusetts citizens. There were even recipients who were deceased.

The DTA’s existing program integrity processes could uncover eligibility issues, but they involved cross-checking applicants’ information across multiple systems and databases – usually manually. This time-consuming approach meant that irregularities would not surface until well after the application and benefit issuance process was underway. Since benefits had already been issued in order to assure timely delivery, the DTA had to use a pay-and-chase model to recoup the inappropriate payments.

Learn about Xerox healthcare solutions; how we automate workflows and bring process improvements to the delivery of benefits to your citizens.

Automating Integrity

Massachusetts needed a more proactive method of avoiding inappropriate payments. The agency wanted an automated checklist that could consolidate the many different data sources that help determine eligibility. The system had to compel reviews at strategic locations within the application, re-evaluation, recertification and case maintenance processes. This checklist also had to work with the Commonwealth’s current eligibility system.

Xerox developed the Program Integrity Checklist (PI Checklist). This automated tool enables DTA to scan applications, re-certifications and re-evaluations for the Commonwealth’s SNAP, TANF and Emergency Aid to the Elderly, Disabled and Children programs.

The PI Checklist reviews an applicant’s information against more than 20 external data sources to against the agency’s eligibility criteria,  including job status, income level, incarceration status. It also verifies Social Security numbers,  and links to other states’ databases to ensure that applicants are not already receiving benefits from other states.

When it finds discrepancies, the application is flagged for further review. A DTA caseworker contacts the applicant, who must confirm the information in question and/or provide additional documentation before the application is fully processed.

An assessment of state fraud control units from the American Bar Foundation praised “characteristics indicative of Massachusetts’ position at the forefront of fraud control efforts and innovation.” The results were revealed in a June 22, 2015, letter delivered to the Massachusetts Department of Transitional Assistance.

Saved $15.5 Million in Year One

“The partnership with Xerox has produced a state-of-the-art eligibility checklist that insures that only the truly needy – not the greedy – receive valuable public assistance benefits,” said William Daly, DTA’s assistant commissioner of Program Integrity.

After just over a year, the PI Checklist has allowed the Commonwealth to identify and prevent more than $15.5 million in inappropriate payments. More than saving money, this result frees-up more resources to help Massachusetts’ neediest citizens.

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