Governor Mike Braun:
“Indiana is proud to partner with CMS and Oracle on this state of the art pilot program to help states eliminate fraud. We are proud to lead the way and look forward to showing every other state how it’s possible to administer programs low income citizens need while still protecting taxpayer dollars.”
The pilot represents one of the most ambitious efforts in the nation to modernize Medicaid program integrity through real-time analytics, cross agency collaboration, and AI driven enforcement.
Objectives of the Pilot Program
Demonstrate Prepayment FWA Detection
Validate that AI/ML can analyze near realtime Indiana Medicaid claims data to identify suspect billing patterns—such as upcoding, phantom services, and geographic anomalies—before claims are paid.
Produce recommended claim edits, prepayment controls, prior authorization triggers, and policy interventions that prevent improper payments at the source.
Enable Collaborative Fraud Investigation
Provide CMS, Indiana, Medicaid Fraud Control Units (MFCUs), Unified Program Integrity Contractors (UPICs), and law enforcement with a shared analytics platform that enables concurrent, barrier free modeling and case development.
Accelerate Enforcement Actions
Deliver AI generated, investigation ready case packages—including structured evidence, provider timelines, and risk profiles—to speed enforcement against high risk providers.
Assess Scalability
Evaluate whether the models and platform designed for Indiana can be expanded to additional state Medicaid programs.
Identify Data & Policy Constraints
Surface technical, legal, and privacy barriers that must be addressed for largescale AI enabled FWA prevention.
Produce Transferable Findings
Deliver a final proof of concept report with lessons learned, findings, and recommendations that CMS leadership can use to inform future program integrity strategy and investment decisions.