Program Integrity & Compliance

Medicaid agencies must monitor for post-payment fraud, systemic waste, and abuse to comply with state and federal regulations. We collaborate with clients and partner entities, including states’ Medicaid Fraud Control Units and their Office of the Inspector General, to mitigate abuse, while extending educational opportunities to providers.

What Challenges You

Medicaid agencies like yours are charged with ensuring the integrity of the Medicaid program. Federal regulations require that the agencies perform post-payment audits of the claims payment system; federal state plans must incorporate program integrity reviews and data mining across all provider types, including managed care plans. In addition, unexpected events, including paused federal and state program integrity requirements and new healthcare delivery methods, can lead to additional challenges for states.

Why Choose Us

Our solutions are highly innovative, but it’s our team of experts, with decades of experience collaborating with state Medicaid agencies, who set us apart. As long-standing partners with our clients, we function as a secondary arm of your program integrity unit, working with you to identify patterns, develop new responsive algorithms, shift future outcomes, and provide ongoing training to agency staff.

How We Can Help

  1. 1

    We help our clients recover millions of dollars in costs savings by rooting out and safeguarding against Medicaid fraud, waste, and abuse, putting that money back into providing care to members.
  2. 2

    Our approaches enhance states’ ability to deliver and sustain quality care to Medicaid members.
  3. 3

    With a customized program integrity component, our data analytics solution identifies problematic payment activities often overlooked by large-scale software solutions.

Our Impact

Recovered Dollars, Positioned for Reinvestment

Over the past two years, our proprietary algorithms and desk audits have resulted in over $30 million in identified recoveries in one state. Similarly, during the last three years, we helped a state recover over $10 million by operationalizing the intake and review of provider self-disclosed overpayments for all provider types. Our program integrity efforts referred multiple providers to a Medicaid Fraud Control Unit, resulting in over $38 million in recoveries and prosecutions.