Program Integrity

Capabilities

Complex Medical Review
Statistical and Data Analysis
Medical Coding and Billing Validation
Fraud Investigations
Error Rate Detection and Calculation
Overpayment Identification
Fraud Algorithm Development
Complex Sampling Design and Methodology
Performing Compliance, Claims Processing, and Other Audits

Expertise

SAS, SPSS and R Programming
Investigations
Coding, Clinical Documentation, and Medical Necessity Reviews
Medicare Part A, Part B, Part C and Part D Data
Medicaid and CHIP
Health IT Systems (CMS Standard Systems and MMIS)
Mailroom and call Center operations in support of program integrity investigations
Scanning and imaging records, retaining and archiving records, electronic transmission of records including encryption in compliance with government security standards
Development and use of proprietary software and tools to detect fraud, waste and abuse

Experience

CMS CERT DC
CMS Medicare Drug Integrity Contractor (MEDIC)
CMS Medicare Part D Recovery Audit Contractor (RAC) Data Validation Contractor
CMS MEDIC Retiree Drug Subsidy (RDS) Audit Contractor
CMS Zone Program Integrity Contractor (ZPIC) Physician Review
CMS Zone Program Integrity Contractor (ZPIC) Data Architecture
CMS Zone Program Integrity Contractor (ZPIC) SAS Programming
CMS Review of Provider Medicaid Integrity Contractor Algorithm Development
CMS PERM Statistical Contractor
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