Modivcare's Technology-Enabled Approach to Fraud, Waste & Abuse Prevention

A Layered, Technology-Enabled Approach to Program Integrity

Protecting access. Strengthening accountability.

Across healthcare, organizations are moving from a traditional “pay and investigate” approach to a proactive framework that helps prevent, verify, detect, and protect against fraud, waste, and abuse. Increasingly, states and payers expect and demand a layered approach to fraud, waste and abuse (FWA) detection and prevention including pre-payment controls, timely validation, explainable decision-making, and stronger payment integrity throughout the transportation lifecycle.

Modivcare’s FWA ecosystem combines configurable business rules, workflow automation, digital trip verification signals, advanced analytics, explainable AI, and operational expertise to help clients identify risks, reduce inappropriate payments, strengthen oversight, and protect precious healthcare dollars. By integrating these capabilities into a unified framework, Modivcare identifies risks earlier, verifies service delivery more consistently, detects emerging patterns, and strengthens payment integrity.

As AI and analytics continue to evolve, so does our investment in next-generation capabilities that improve transparency, efficiency, and program stewardship. Rather than relying on opaque “black box” models, Modivcare emphasizes explainable AI that complements configurable business rules and human expertise, providing clients with transparent, auditable decision support.

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Why A Layered Approach to FWA Matters

  • It Protects Healthcare Dollars – Allowing Modivcare to identify risk earlier and reduce inappropriate payments before funds are released.
  • It Improves Payment Integrity – Supporting consistent, transparent decision-making that strengthens audit readiness and compliance.
  • It Reduce Administrative Burden – By automating routine reviews so investigators can focus on the highest-risk activity.
  • It Enhances Provider Relationships – Allowing for more targeted review processes and reducing unnecessary friction for legitimate transportation providers while allowing investigators to focus on higher-risk activity.
  • It Improves the Member Experience – By supporting access to medically necessary transportation through earlier issue identification reducing avoidable friction, unnecessary follow-up, and payment delays.

  

  • It Supports Effective Program Stewardship – Clients increasingly expect transparency into why claims and transportation activity were approved, denied, or routed for review. Explainable AI, structured evidence, and configurable workflows provide greater visibility into payment integrity while strengthening accountability, compliance, and confidence in program oversight.
  • It Delivers Improved Transparency – Each of these approaches help translate FWA signals into meaningful reporting – highlighting surfaced risks, reporting activity that was prevented or routed for review, identifying where utilization patterns are changing, and suggesting actions that may strengthen program oversight.

Why Modivcare

Modivcare delivers a layered payment integrity ecosystem that goes beyond traditional fraud detection. Rather than relying solely on retrospective reviews, our layered approach integrates prevention, verification, detection, and protection into a single operating framework.

An effective layered approach to payment integrity begins with configurable business rules, workflow automation, digital evidence signals, and supporting documentation. Advanced analytics, machine learning, and AI-assisted insights build upon that foundation, helping investigators prioritize high-risk activity while maintaining transparency, explainability, and human oversight.

What differentiates Modivcare:

  • Configurable decisioning aligned to individual client and program requirements
  • Explainable AI supported by transparent business rules and human oversight
  • Composite risk scoring to help focus resources on higher-risk activity
  • Digital trip verification signals (where available)
  • Structured evidence packages for investigation, audit, and client reporting
  • Experienced payment integrity, compliance, and operational teams
    • Advanced analytics that support continuous improvement and client insight

The Modivcare Payment Integrity Framework

Examples of Risk Indicators

Modivcare’s layered payment integrity framework is designed to help identify a range of transportation-related fraud, waste, and abuse risks, including:

  • Duplicate rides or claim activity
  • Mileage reimbursement anomalies
  • Potential ghost-trip indicators
  • Unusual driver-member relationship patterns
  • Impossible or unusual routing patterns
  • Attendance or documentation discrepancies

Every concern is reviewed with discipline, documentation, and respect for the members and partners involved.

The Future of Intelligent Payment Integrity

Building on today’s capabilities, Modivcare continues to invest in technologies that will further strengthen payment integrity over time. These future capabilities represent our long-term vision and are designed to complement—not replace—the configurable business rules, workflow automation, and human expertise that form the foundation of our payment integrity strategy. These capabilities represent areas of ongoing investment and may vary by client, market, mode, and implementation timeline.

Areas of ongoing investment include:

  • AI-assisted anomaly detection
  • Graph-based relationship analysis
  • Longitudinal event intelligence
  • Next-best-action recommendations
  • Expanded client intelligence and dashboards
  • Predictive models to help prioritize payment integrity review

These investments build on today’s platform while maintaining transparency, explainability, and human oversight.

Looking Forward

Transportation payment integrity is evolving from retrospective fraud detection toward proactive, intelligent program integrity. By combining configurable business rules, workflow automation, digital trip verification signals, advanced analytics, explainable AI, structured evidence, and experienced investigators into a unified framework, Modivcare helps clients reduce FWA risk, strengthen payment integrity, and administer transportation benefits through our comprehensive prevent, verify, detect, and protect framework to deliver better outcomes for clients, providers, and the members they serve.