This RFP seeks a comprehensive Fraud, Waste, and Abuse (FWA) solution that supports detection, prevention, investigation, and reporting across claims, encounters, pharmacy, eligibility, and provider data. The selected platform must deliver advanced analytics, rules‑based detection, case management, model governance, and compliance‑ready reporting aligned with CMS, state Medicaid, and OIG requirements.
Project Guidelines
1. Scope
Solution must support:
- Data ingestion and validation
- Predictive analytics and rules‑based detection
- Case management and investigations
- Prevention controls
- Reporting and audit support
- Model governance
2. Compliance
Must align with:
- CMS Program Integrity
- State Medicaid rules
- HIPAA security requirements
- OIG audit expectations
3. Technical Requirements
Solution must provide:
- Modern APIs
- Multi‑vendor interoperability
- Scalable architecture
- Strong security and disaster recovery
4. SIU & Operational Requirements
Must include:
- Case lifecycle tracking
- Entity linking & graph analytics
- Audit trail exports
- Escalation logic
- Investigation dashboards
5. Evaluation Criteria
Vendors will be scored on:
- Technical maturity
- Detection accuracy
- Integration strength
- Compliance alignment
- Case management depth
- Pricing & TCO
- Experience & case studies
6. Submission Requirements
Vendors must submit:
- Completed questionnaire
- Case studies
- Certifications/audit evidence
- Pricing & 5‑year TCO
- NDA, BSA, MSA
NOTE:
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You’ll set a password and receive a verification email with a code. Once your account is verified, you can begin the RFP.
If you run into any issues, please reach out to Denise de los Reyes at dreyes@ilshealth.com.