• Please note that while there is no specific target for this measure, the goal is to increase cost avoidance amounts over time by increasing the number of providers we are in contact with and the removal of beneficiaries that are no longer eligible for benefits.

This measure is important because the Special Investigations Unit (SIU) strives to increase the quarterly cost avoidance amount over time by increasing the number of providers we are in contact with and the removal of members that are no longer eligible for benefits. The chart depicts the quarterly impact of SIUs cost avoidance measured to date for both providers and members.

The SIU seeks to interact with providers through proactive provider audits, educational outreach opportunities, and case referrals.  The SIU strives to educate providers as appropriate, recover funds when necessary, and avoid wasting Medicaid funds.  One of the SIU approaches to prevent the fraud, waste, and abuse of Medicaid funds is to avoid the cost entirely.  In essence, when you cost-avoid unnecessary or inappropriate funds from being paid out, the program is preventing waste and abuse, which minimizes “pay and chase.”  Cost avoidance is estimated from point of contact with the provider and the estimated savings from a changed billing pattern.  The performance data compiled to date indicates the more providers SIU contacts, the more cost avoidance is realized.

The SIU unit also records cost avoidance when we are involved in the removal of members from Vermont Medicaid that are no longer eligible for benefits.  When members are no longer residents of Vermont and reside in another state, their benefits in Vermont would be terminated.  Beginning in Q3 of SFY25, the SIU initiated formal plans to transition this residency verification work to another unit within the department and did not work on new residency matches. Additionally, these savings were based on monthly per member per month (PMPM) savings for attributed members of VT Medicaid’s Accountable Care Organization (ACO).  The ACO program ended December 31, 2025, and will not produce PMPM costs per member moving forward.  Over time, this number has only existed as a 12-month projection from prior residency eligibility work and will eventually drop to zero due to the sunsetting of the ACO program.  With residency verification tasks transferred to another unit, the SIU unit has experienced an increase in provider cost avoidance, thanks to the additional staff hours now available to focus on provider fraud, waste, and abuse.

Narrative last updated: 04/08/26

• Clinical Operations Unit
• Member Provider Services Unit
• Health Access, Enrollment and Eligibility Unit
• Medicaid Providers
• Gainwell Technologie