Strengthening Medicare Program Integrity: The Power of Deterrence in Combating Fraud, Waste, and Abuse
In the ongoing effort to protect the Medicare program, deterrence stands out as a powerful and cost-effective strategy. While detection and enforcement remain critical, deterrence shifts the focus from reacting to fraud after it occurs to preventing it before it starts. By increasing the perceiv...
Navigating the No Surprises Act: A New Era of Transparency in Healthcare
The No Surprises Act, implemented by the Centers for Medicare & Medicaid Services (CMS), marks a major milestone in protecting patients from unexpected medical bills. This landmark legislation, effective January 1, 2022, addresses long-standing issues related to surprise billing and healthca...
The Fraud Beneath the Surface: Investigating Amniotic Wound Care Claims
The surge in the use of amniotic-derived skin substitutes for chronic wound management, especially among diabetic and elderly patients, has opened the door to significant fraud, waste, and abuse across Medicare, Medicaid, and commercial insurance. With per-unit costs running into thousands of do...
From Policy Gaps to Compliance Confidence: Strengthening Grant Management Under 2 CFR 200
Part 2: Practical Steps to Strengthen Your Compliance Framework
What Effective Policies and Procedures Look Like
Not all written policies are created equal. To satisfy Uniform Guidance requirements and withstand audits, policies and procedures must be:
Comprehensive – Covering all area...
Suspect Payments in Medicare Advantage: Why Transparency Matters
Understanding the context of “Suspect Payments”
In Medicare Advantage, payment practices work best when they are clear, consistent, and aligned with beneficiary needs. Strengthening oversight not only reduces compliance risk but also reinforces trust in an organization’s commitment to d...
From Policy Gaps to Compliance Confidence: Strengthening Grant Management Under 2 CFR 200
Part 1: Why Written Policies and Procedures Matter
The Most Common Federal Grant Audit Finding and How to Avoid It
Federal grants play a vital role in advancing public service, driving innovation, and supporting communities across the United States. Agencies and organizations that receive fe...
The Rise of GLP-1 Fraud in Medicare, Medicaid, and Commercial Insurance: Data Driven Approaches to Investigations
The booming demand for GLP-1 receptor agonists such as Ozempic, Wegovy, and Mounjaro, used for weight loss and Type 2 diabetes, has sparked a surge in fraudulent activity across Medicare, Medicaid, and commercial insurance. From inappropriate prescribing and billing anomalies to falsified diag...
Highlighting Public Tools That Advance Medicaid Transparency and Oversight
Let’s talk about…the power of public data tools.
Public data dashboards are vital tools for strengthening accountability in healthcare programs. In Medicare and Medicaid, they equip beneficiaries, agencies, and policymakers with insight into how services are delivered and how that information...
Advancing Healthcare Claims Technology
IntegrityM partners with AI and machine learning developers to embed clinical, regulatory, and compliance expertise into the design and deployment of healthcare automation tools. As a trusted healthcare partner, we guide the use of AI/ML technologies in medical coding, claims analysis, and ...
What Is Statistical Extrapolation and Why Does It Matter?
Extrapolation is a statistical method used to estimate values for an entire population based on a smaller, randomly selected sample. In healthcare audits, this technique allows auditors to review a manageable subset of claims and project the findings to the full universe, saving time and resour...
