A modular, cloud-based solution delivering real-time payment integrity analysis and case management integration.

Protecting Enrollees at a Reasonable Cost


The Call for Program Integrity

The Center for Medicare and Medicaid Services (CMS) has committed itself to Program Integrity (PI), promoting modular solutions for state Medicaid systems (MMIS) to encourage reuse among states, minimize customization and increase competition. Errant payments from fraud, waste, and abuse (FWA) costs health plans as much as $360 Billion each year, diverting dollars away from safeguarding the health and welfare of enrollees. How much of this is happening in your MCO?

Our Program Integrity Blueprint

Payment Integrity and case management are key components of a Comprehensive Medicaid Integrity Plan (CMIP). Your Medicaid Information Technology Architecture (MITA) needs open, scalable, modularized and best-in-class analytic solutions to drive integrity.

Our Program Integrity solutions are comprehensive, responsive, low-maintenance, and cost-effective, requiring a minimal investment of capital and effort to implement. With our advanced FWA analytics and flexible case management extensions, your organization is empowered to reduce costs and better serve plan members. We take care of the heavy lifting, so you can focus on your plan operations


The Power of Program Integrity

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Facilitate price negotiations and integrity checks with pricing that leverages UCR and all 16 Medicare Prospective Payment Systems.

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Assess payment compliance at a granular level with advanced Medicare, Commercial and Medicaid analytics logic.

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Receive FWA analytics and reporting at the enrollee and provider levels.

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Case management extensions to pass potential aberrations detected into a functional workflow system in your SIU.

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Special investigation business partnerships to facilitate rounding out your CMIP if needed.

What is your organization doing to protect your health plans, meet CMS requirements, and provide contractor oversight? Contact us to learn more about what Program Integrity can do for your organization.