NAMPI 2026 Codoxo Session

From AI-Generated Leads to Referral to Medicaid Fraud
Control Unit (MFCU): How Program Integrity Investigations
Progress from Detection to Credible Allegations of Fraud

The Georgia Department of Community Health (DCHGA) will share a series of real-world investigations that began with AI-generated investigative leads and progressed through validation and referral to the Medicaid Fraud Control Unit (MFCU). Rather than focusing on a single investigation, the session will examine multiple case studies involving alleged identity theft, services allegedly rendered by unaccredited and/or uncredentialed providers, referring provider irregularities, medically unnecessary services, patient sharing, and other fraud schemes across provider types including primary care, behavioral health, durable medical equipment (DME), and laboratory services.

For each case, DCHGA will discuss the billing scenarios and fraud indicators that prompted further investigation, provider profiles associated with the activity, and the investigative process used to validate concerns through claims analysis, medical record review, interviews, and site visits. Attendees will also explore how DCH collaborated with the Medicaid Fraud Control Unit (MFCU) and other agencies as cases advanced through investigation and referral to state and/or federal law enforcement. While AI helped to identify investigative leads, the session will emphasize the investigative strategies, interagency collaboration, and operational best practices that transformed those leads into actionable referral to MFCU.

Speakers:​

Johnny R. Brooks, MPA, CIG​, Director, Program Integrity, Department of Community Health​, Office of Inspector General, Program Integrity​

Sara Rodriguez, CPC, CPIP, Healthcare Fraud Analyst​, Codoxo

​Moderator:​

Derik Ciccarelli, Six Sigma​, Director, Fraud Scope Operations​, Codoxo​

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