Risk Scoring Proof of Concept (Phase 1 Pilot)

The HHS ASFR Immediate Office requires an improved capability to identify, assess, and prioritize health care service providers that may present elevated improper payment risk or related program integrity concerns.

ASFR already tracks state-level findings associated with Single Audits and needs a more effective means of leveraging those findings, together with other authoritative reference data, to strengthen oversight, improve accountability, and support more informed communication with states regarding questioned costs, improper payments, and related provider risk indicators. This requirement is focused on service-provider analysis and provider record quality. It is not intended to involve patient data processing.

Phase 1 is a six-state, 90-day proof of concept intended to determine whether a standardized risk-scoring and referential matching approach can generate useful, explainable, and operationally relevant results for ASFR and, as appropriate, support coordination with the Office of Inspector General (OIG).