The Department of Health and Welfare is exploring new approaches to strengthen efforts to detect, prevent, and address fraud, waste, and abuse across large public benefit programs.

A Request for Information (RFI) issued this week seeks information about tools, technology, and services that could support program integrity efforts across multiple public benefit programs administered by DHW. The RFI is open Aug. 11- Aug. 31.

While DHW currently has processes in place to prevent, identify, and investigate fraud, waste, and abuse in public benefit programs, the department seeks to identify opportunities to bolster and expand current capabilities. The RFI is a step toward finding additional approaches and tools to detect potential program integrity issues earlier and prioritize investigative resources. 

RFI explores new approaches to prevent, detect, and address fraud, waste, and abuse

DHW currently relies heavily on complaints, tips and staff-initiated referrals to identify potential fraud, waste, and abuse across public benefit programs. The RFI seeks information about available tools and technologies that may strengthen DHW’s program integrity capabilities. 

Among the capabilities DHW is exploring are advanced data analytics, data mining, artificial intelligence and machine learning, pattern and anomaly detection, and technology that could help prioritize potential cases for review.

The department is also exploring a combination of technology and human expertise to help develop cases and route complex, higher-priority cases to program integrity investigators.

Existing safeguards help prevent and address improper benefits

While the RFI looks at potential new approaches, DHW already has safeguards and processes in place to prevent and address improper benefits.

Eligibility safeguards: DHW reviews information used to determine whether an applicant meets eligibility requirements. DHW staff verify required information and use program policies, data sources, and automated tools to determine eligibility before benefits are approved.

Oversight continues after enrollment through eligibility renewals and other checks designed to identify changes that could affect whether someone remains eligible for benefits.

These processes can prevent improper benefits from being issued and can also identify information that warrants additional review.

Suspected beneficiary fraud: Potential fraud can be identified through eligibility reviews, discrepancies in available information, complaints, reports, and referrals from DHW staff and partners. The Division of Self Reliance Integrity Unit reviews referrals, seeks additional information when necessary, and determines what action should be taken. Cases requiring additional fact-finding can be referred to DHW fraud investigators. 

An error or improper payment does not necessarily constitute fraud. Fraud generally involves intentional deception or misrepresentation.

Depending on the findings, DHW can establish an overpayment, impose administrative sanctions, or refer cases for further investigation. Cases with sufficient evidence may also be referred to local prosecutors. 

RFI could inform future steps

The RFI is an information-gathering step, not a solicitation, and no contract will be awarded through this process. 

DHW will use the responses to better understand available technology and services, potential costs, and whether an enterprise-wide approach could work across multiple benefit programs.

Information gathered through the RFI could eventually be used to develop a formal Request for Proposal.

• To read the RFI, follow this link, locate the Open Events box in the lower right corner, and scroll to the Public Benefit Program Integrity and Fraud, Waste, and Abuse entry.

The Idaho Department of Health and Welfare is dedicated to strengthening the health, safety, and independence of Idahoans. Learn more at healthandwelfare.idaho.gov.