The IntegrityM Blog


Network Adequacy: Meeting Requirements and the Impact of the ACA

The Affordable Care Act directed the Secretary of Health and Human Services to establish criteria for certification of qualified health plans, to include (1) ensuring a sufficient choice of providers and (2) providing information to enrollees and prospective enrollees on the availability of in-network and out-of-network providers.  45 CFR 156.230, entitled network adequacy standards, requires qualified […]

Read More

How Effective are Criminal Background Checks Really?

A U.S. Department of Health and Human Services Office of Inspector General (OIG) report from October, 2012 offers some interesting insights into the usefulness of criminal background checks for nurse aides. To get to these insights, some setup is needed. Nurse aides work in long-term-care facilities. To work as a nurse aide, individuals must complete […]

Read More

  • Author: IntegrityM
  • Date: October 14, 2015
  • Category:

Healthcare Data Mining for Fraud Detection: Identify and Reduce False Positives to Build Stronger Models

One of the key goals of healthcare data mining is to reduce false positives.  In health care fraud data mining, a false positive occurs when your model identifies a provider that is not engaging in fraudulent activity and that has legitimate reasons for having seemingly aberrant billing. Pursuing false positives can be expensive and time […]

Read More

  • Author: IntegrityM
  • Date: May 7, 2015
  • Category:

Peeling the Onion: Achieving More Significant Results by Digging Deeper into CMS Payment Data

The U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) issued an audit report to the Centers for Medicare & Medicaid Services (CMS) in February 2015 that illustrates how an audit team can achieve more significant results by simply digging deeper. The report entitled CMS Made Payments Associated With Providers After […]

Read More

Contact Us

Get Industry Blog Updates Directly to Your Inbox