Program Integrity

Program integrity directly affects an organization’s bottom line and the clients that they serve. We have experts that target fraud, waste, and abuse with tools to identify noncompliance and erroneously paid claims. Examples of our work include the following:

  • In Massachusetts, we design and oversee initiatives that root out Medicaid fraud, waste, and abuse. We identify and recover overpayments made to Medicaid providers to safeguard against inappropriate payments for Medicaid services.
  • We conduct audits focused primarily on compliance with state and federal administrative and billing regulations. Our team has audit expertise in all Medicaid provider types, and participates in a variety of provider audit initiatives, in addition to nursing homes and hospitals. 
  • Our data analytics solution, with a customized program integrity component, identifies abuse activities often overlooked by the standardized processes of largescale software solutions. We include pharmacy costs and controls that are essential to a strong, effective program integrity effort.

Our Results

  • In 2010, more than $17 million was recovered for the Commonwealth of Massachusetts as a result of our provider recovery and compliance activities.
  • Through audit initiatives, we have saved Massachusetts more than $9 million annually through the direct recovery of overpayments.