RFI+ND+Fraud+Waste+Abuse+System_FINAL.docx

State of North Dakota North Dakota Department of Health and Human Services Medical Services Division 600 East Boulevard Ave.

Bismarck, ND 58505

Request For Information (RFI) Solicitation Number: 325-25-415-57 RFI Title: Fraud, Waste, and Abuse System Date of Issue: September 2, 2025

Section 1: Overview & Instructions

1.1 Purpose

The state of North Dakota, acting through its Department of Health and Human Services, Medical Services Division (State) is seeking to schedule online/virtual strategy discussions from interested Suppliers with experience in fraud, waste, and abuse system. The intent of these discussions is to obtain feedback from Suppliers to assist the State in developing a more accurate Scope of Work and overall approach for a possible solicitation for a comprehensive system to assist the Agency in combating fraud, waste, and abuse by analyzing and identifying potential findings, leveraging third party data sources, providing case tracking aligned with the case lifecycle, comprehensive financial tracking functionality, and enabling comprehensive reporting.

This is not a solicitation for quotations, bids, or proposals. No contract award will result from this RFI. The State firmly believes this process will help it to develop a solicitation that is clear and can be administered more efficiently and effectively; however, participation in these discussions is completely optional (they are NOT mandatory in order to participate in the future solicitation).

1.2 Format of Virtual Discussion

The format of these informal discussions will be performed virtually online via video conferencing tools (i.e., Zoom, Teams, Webex, etc.). The content and topics of the strategy discussions are shown in Section 3. The State is NOT requesting a formal written response to these questions or topics (as is common in most traditional RFIs). All information will be collected via the conference call/video call, which will be performed on a “1-on-1” basis between each Supplier and the State (not as a group meeting). The State anticipates spending about 1-hour on each call.

The State intends to use information gathered from these discussions to help ensure that the future solicitation is fair and open and provides the information necessary for suppliers to be able to provide accurate proposals. The State plans to schedule discussions with the first five (5) Suppliers to submit a request but reserves the right to hold additional discussions in order to capture diverse Supplier perspectives. The State shall not reimburse the Supplier for any expenses incurred responding to this RFI.

The State does not have any requirements of who can attend the meeting, or their role/position. The Supplier can select the best person(s) to attend. The meetings will be led by the Point of Contact identified in Section 4. Suppliers will be permitted 5-10 minutes to introduce their company for context. The remainder of the time will be spent discussing the Supplier’s answers to the questions provided in Section 3. Other than general procurement questions, the state will not answer any questions about the project or upcoming solicitation; however, the state will be taking note of questions to ensure that they are answered proactively in the solicitation document.

1.3 Key Dates

The RFI timetable is shown below, but the State may adjust/modify this schedule as needed.

1.4 Point of Contact

All questions, inquiries, or communications regarding this RFI or the fraud, waste, and abuse system must be directed to the Point of Contact listed below (via email). Suppliers shall not contact any other State employee.

Angie Scherbenske IT Procurement Officer Department of Health and Human Services Email: akscherbenske@nd.gov

Section 2: Background Information

2.1 Background Information

The North Dakota Department of Health and Human Services, through its Medical Services Division, Program Integrity Unit (PIU), is responsible for administering and managing Medicaid (Title XIX) audit and compliance initiatives. PIU is charged with detecting, investigating, and preventing fraud, waste, and abuse of the Medicaid Title XIX, CHIP Title XXI, and waiver programs. PIU initiates administrative sanctions and refers cases with credible allegations of fraud for criminal investigation and prosecution.

Currently, North Dakota Medicaid has approximately 23,020 individual providers and 3,391 group providers enrolled. The current membership enrollment for Traditional Medicaid is 84,612 and Medicaid Expansion is 23,536 for a total of 108,148. Traditional Medicaid claims, to access from both individual and group providers, are approximately 3.5M annually.

The current Managed Care Organization (MCO) for Medicaid Expansion is BlueCross BlueShield of ND (BCBSND). BCBSND adjudicates all Medicaid Expansion claims; those claims are then sent to MMIS for historical reporting. Medicaid Expansion claims, to access from both individual and group providers are approximately 800,000.

Claims retention is seven (7) years; however, our MMIS system currently has more than seven (7) years’ worth of data.

2.2 Unique / Challenging Conditions

The PIU is a small unit with limited resources. Improving the PIU’s use of automation will allow for faster data processing, reduced error potential, and free up staff resources to focus on what the data means instead of the time-consuming task of producing the calculations.

Existing software has limited automation, analytics, and reporting capabilities. North Dakota (ND) Medicaid does not have a current system for fraud detection. Cases are manually researched or referred by outside entities.

Interface to MMIS or Data Warehouse: Integration to the MMIS or Data Warehouse will be required to access data needed for fraud detection. These are complex data sets and will take a significant amount of time to develop custom extracts. The ideal application would utilize these existing data sets to perform the analysis, so data does not need to be exchanged and stored in another application. If the application relies on its own data set, that can be accommodated as well but not preferred.

Integration into MMIS would originate through our System Integration Platform (SIP), which is currently under development. The integration component is driven by InterSystems IRIS Data Platform that supports secure, bidirectional data exchange using healthcare interoperability standards such as HL7 v2.x, HL7® FHIR® R4, C-CDA, and X12 EDI (including HIPAA transactions such as 270/271 eligibility, 276/277 claims status, 837 claims, and 278 prior authorization). It also natively supports RESTful APIs and SOAP web services for system-to-system integration. This would also require custom integration between our SIP and MMIS or Data Warehouse data sets.

2.3 Future Goals & Outcomes

PIU’s overall goal is to improve the detection, identification, and review of suspected fraud, waste, and abuse in the Medicaid Program. The State is seeking an innovative way to detect fraud using information technology and expansion of data analysis techniques. The potential system shall be of high quality and have functions that are comprehensive, complete, and provide accuracy in analysis and reporting. The solution shall leverage industry standards and best practices to review Medicaid provider activities, audit claims, identify overpayments, eliminate and recover improper payments, and track cases from referral to collection and recovery.

Expected outcomes would include but are not limited to:

· Combat fraud and other improper provider activities.

· Avoid inappropriate Medicaid payments.

· Recover inappropriate Medicaid overpayments.

· Coordinate fraud, waste, and abuse activities within the Agency, and with other State and Federal agencies.

· Ensure the overall integrity of the Medicaid Program by enforcing program requirements.

· Maintain enrollment of quality providers.

· Ensure the accuracy of Medicaid payments to providers.

2.4 Upcoming Solicitation

· The State anticipates a Request for Proposal (RFP) solicitation upon availability of funding review, RFI results, and contingent on approval from CMS (Centers of Medicare and Medicaid Services).

· The State’s RFP will focus on requirements needed by the State and weighted criteria. Cost is not the only deciding factor. The State’s intent is to award a single vendor.

Section 3: Script for Strategy Discussions

A written response to these questions is NOT required. The State will conduct virtual discussions with interested Suppliers to address these items. The supplier can prepare a presentation to assist with the discussion if they would like (but they are not required to do so).

1. To enable your firm to prepare an accurate proposal at the RFP/RFX stage, what is the most critical information for the State to provide about our Current Conditions (what critical things do you need to know about our current environment)?

2. To enable your firm to prepare an accurate proposal at the RFP/ITN stage, what is the most critical information for the State to provide about our Future State Requirements (are there any goals, objectives, or desired items that we haven’t thought of, or should consider)?

3. In general, who are the most critical 3-5 personnel (from the Supplier side) that are essential to the overall success of this program?

4. What technical details will be helpful for the state to write the RFP. For example; integration models, hosting model, etc.

5. What would be the ‘best’ way for the State to collect and compare costing information from suppliers, to allow the State to compare proposals ‘apples-to-apples’. Could you provide us with an example(s) of a costing templates that you would recommend using?

6. What is an average total cost for a system to include initial system cost and ongoing support and maintenance? This is not considered a quote, nor will vendor be held to this cost in any way. The State desires to have an average for future planning.

7. What are your thoughts about our schedule timelines? Are we being realistic? OR What is realistic with a small staff?

8. Are there any other factors/issues/items the State be considering at this time?

Strategy Discussions for Fraud, Waste, and Abuse System

Response Form

Suppliers that would like to participate in the virtual discussions should complete this form to reserve a time slot. Please identify a point of contact that the State can contact to set up the virtual meeting.

Company Name

Point of Contact name

Phone number

Email Address

Please identify the preferred dates/times for the virtual call (as shown in the table below). Due to the number of Suppliers that may RSVP, please identify at least 2-3 dates/times that will work for your team (so we can try to accommodate everyone). RSVP as soon as possible. Timeslots will be scheduled on a first-come, first-served basis. Once your timeslot is confirmed, the State will provide a link to the conference-call or video-call.

Monday September 17, 2025 Wednesday September 18, 2025 Thursday September 19, 2025 Friday

8:05 – 9:00 am

11:05 am – 12:00 pm

Not available

Not available

Not available

Please complete and send this form via email to akscherbenske@nd.gov

RFI #325-25-415-57 Fraud, Waste, and Abuse System Page 5 of 5