Program‑integrity unit details recent recoveries, new tools and an expanded data program

Ralph Choad, chief operations officer, and Stephanie Denning, deputy director of Medicaid operations, briefed the commission on program integrity work that ranges from analytics to prepayment claim edits and post‑payment audits.

Choad highlighted large recoveries from correct third‑party billing and Medicare coordination: "There are approximately 150,000 people out of our 1,300,000 people who are actually dual eligibles," he said while describing how ensuring Medicare is primary saves Medicaid dollars. Denning explained operational changes such as prepayment editing on NEMT claims that avoided about $15 million in inappropriate payments last year.

The department said it will expand tools with a federal UPIC contractor to sample claims and use extrapolation authority — recently authorized by the General Assembly in narrow cases — to increase recoveries. Commissioners asked for multi‑year recovery history and the department agreed to provide last‑three‑to‑five‑year recoveries and the forecast the department shares with the governor’s office so JBC staff can review assumptions.