Alexandria, VA, September 11, 2023 – Integrity Management Services (IntegrityM) is honored and pleased to announce that it has been recognized as an honoree on the prestigious OrangeSlices’ 2024 Elev8 GovCon list, which recognizes companies that meet higher standards for culture, engagement, and giving back. IntegrityM has been identified as #doingittherightway with outstanding results in…
Alexandria, VA, June 27, 2023 – Integrity Management Services (IntegrityM) is honored and excited to announce that it has been named a finalist in the highly esteemed 2023 Moxie Award. The Moxie Award recognizes and celebrates businesses that exhibit boldness, innovation, and the spirit of Moxie. The Moxie Award distinguishes companies, nonprofits, and associations for…
The U.S. government won over $5 billion in healthcare fraud cases in 2021 according to the HHS Annual Report. That’s a huge number—but it only covers the dollar amount of fraud successfully found through investigations and reporting. Combatting the billions of dollars in fraud each year is the work of specialized investigators committed to keeping…
The signing of the Inflation Reduction Act in August of 2022 brought some immediate relief for Americans with Medicare prescription drug coverage and will continue to drastically impact drug prices as implementation continues. Already in effect as of January 2023: a $35 cap per month on insulin for Medicare prescription plan enrollees, Medicare beneficiaries receive…
FOR IMMEDIATE RELEASE – Integrity Management Services, Inc. (IntegrityM) has just been recognized as being among OrangeSlices’ most recent Elev8 GovCon honorees. The Federal GovCon sector continues to be one of the most complex and competitive marketplaces in the world and the consistent and long-term winners of today and tomorrow are those companies which understand…
The National Science Foundation (NSF), Office of Budget, Finance and Award Management (BFA) awarded Integrity Management Services, Inc. (IntegrityM), a competitive Woman-Owned Small Business set-aside federal prime contract. NSF is an independent Federal government agency with the mission “to promote the progress of science; advance the national health, prosperity, and welfare; and to secure the…
IntegrityM has been named one of DCA Live’s “Red Hot GovCon Companies” for 2022. This list recognizes the Washington D.C. region’s “fastest growing and most exciting companies” within the federal contracting arena. “We are honored to be ranked among this lineup of dynamic GovCon firms,” said Nisha Shajahan, IntegrityM President and CEO. “As a women-owned…
IntegrityM today announced that President and CEO Nisha Shajahan was selected as a finalist for the 14th Annual Small and Emerging Contractors Advisory Forum (SECAF) Awards. Winners will be announced at the Awards Gala on Thursday, May 5, 2022. The event honors small and emerging government contractors and the players in the industry that rely…
For the second time, IntegrityM has been recognized at the National Small Business Federal Contracting Summit with the U.S. Women’s Chamber of Commerce (USWCC) “Stellar” Award. This category recognizes “exceptional contractors who have shown exemplary growth, quality, and are positioned as leaders within the contracting community.” The USWCC’s Women Contractor Awards recognize outstanding performance among…
Author: Natasha Williams, Chief Operating Officer There is a wave of excitement in the industry surrounding artificial intelligence (AI), and not without reason. AI, with its ability to synthesize massive quantities of information at lightning speed, promises limitless possibility. I share in the collective optimism surrounding this new frontier. The detection and prevention of fraud,…
Technology doesn’t have to be complicated. IntegrityM CTO Swathi Young’s #TechTalk series is designed to provide quick, digestible explanations of the latest trends in healthcare technology and innovation so that you can stay ahead of the game before you finish your morning coffee. The Agile Manifesto came into existence during the turn of the twenty-first…
IntegrityM strongly encourages new ‘covered recipients’ to familiarize themselves with the Open Payments system, so that they can have a successful experience in CY2022. Open Payments Program Background: Under the Physician Payment Sunshine Act (Section 6002 of the Patient Protection and Affordable Care Act of 2010 “PPACA”), the Centers for Medicare and Medicaid Services (CMS)…
Technology doesn’t have to be complicated. IntegrityM CTO Swathi Young’s #TechTalk series is designed to provide quick, digestible explanations of the latest trends in healthcare technology and innovation so that you can stay ahead of the game before you finish your morning coffee. Artificial Intelligence, Machine Learning, Robotic Process Automation; these words have spread across…
IntegrityM’s C.O.D.A. (COVID-19 Outreach Digital Assistant) was selected as a winner of a 2021 Innovation Award by ACT-IAC, a non-profit recognized as the premier public-private partner for the government tech community. C.O.D.A. is IntegrityM’s proprietary AI chatbot that harnesses powerful natural language processing (NLP) to streamline current public safety efforts that have arisen as a…
While combating fraud, waste, and abuse is a federal initiative upheld by each state, administrators achieve this through various means. Some state OIGs report that their work is primarily focused on beneficiary fraud, while some work in both beneficiary and provider fraud. Furthermore, state OIGs do not always see the same types of fraud, waste,…
IntegrityM has been named a finalist for the 2021 Moxie Awards, which is an annual award program recognizing companies that have demonstrated boldness and innovation as an integral part of their growth strategy. Nominees are evaluated on innovation, growth, industry leadership, community service and local achievements. The nomination comes to IntegrityM, a certified women-owned small…
ALEXANDRIA, VA. — IntegrityM was recently awarded the addition of Information Technology SIN 54151S for IT Professional Services and SIN 54151HEAL for Health IT Services to our existing GSA Multiple Award Schedules (MAS). This award follows the company’s appointment of AI expert Swathi Young as its inaugural Chief Technology Officer to spearhead the company’s tech and…
ALEXANDRIA, VA: On January 28, 2021, Women in Technology (WIT) named IntegrityM Chief Technology Officer, Swathi Young as a finalist for the WIT Leadership Awards “STEM Leadership” category. This annual awards program “identifies, recognizes and celebrates female professionals who are leaders in the technology field and bring a unique vision and talent to the industry.”…
Author: Jennifer Tryder, RHIA, CHC, Audit Program Director, IntegrityM An audit guide is a documented step-by-step method for conducting an audit focusing on objectives and scope. An audit guide supports many functions including serving as the primary source for the audit process, assisting new auditors in their professional development, providing guidelines for applying audit techniques,…
ALEXANDRIA, VA, October 26, 2020 — Intara Talent Solutions, a new niche talent agency catering to healthcare investigations and program integrity, announced their official launch this month. Intara Talent Solutions offers commercial and federal clients access to a robust network of experienced and pre-vetted healthcare and investigative specialists, and provides a comprehensive and tailored consultation package to streamline the…
IntegrityM Chief Technology Officer Swathi Young has been selected by a panel of current and former Federal and Industry leaders from across the Federal IT sector for the G2xchange 2020 Leading for Impact, Women in Leadership Award. These awards recognize and celebrate women guiding, mentoring, and driving the industry through their impactful leadership; driving technology…
A well-known truism from philosopher Aristotle, is: “We are what we repeatedly do. Excellence is not an act, but a habit.” When running a small business, your world is governed by commitment to excellence and continuous improvement of employee engagement, customer service, operations, program delivery, etc. Executives are forever navigating the tension between ambition and…
Author: Natasha Williams, Chief Operating Officer, IntegrityM A well-known truism from philosopher Aristotle, is: “We are what we repeatedly do. Excellence is not an act, but a habit.” When running a small business, your world is governed by commitment to excellence and continuous improvement of employee engagement, customer service, operations, program delivery, etc. Executives are…
Data Analytics is an indispensable tool being used in COVID-19 recovery efforts. Many of us take for granted that this is being used, but are not quite sure how. IntegrityM CTO Swathi Young and COO Natasha Williams break down the basics of Data Analytics and COVID-19 to shed light on the role this field plays….
What is Contact Tracing? Contact Tracing is not new. It has been used to control infectious disease for decades. Contact Tracing is one of the oldest public health tactics and has been used with smallpox, Ebola, tuberculosis, and AIDS. So what exactly is contact tracing? It is the process of supporting patients with suspected or…
Did you know that nurses don’t just defend public health through direct patient care – they’re also crucial team members on the front lines fighting fraud, waste and abuse? Their knowledge represents an irreplaceable asset in any solid medical review team. Medical review is the clinical review of health records, medical bills and supporting data….
The U.S. Department of Veterans Affairs (VA) Veterans Health Administration (VHA) has awarded a 10-year, $1 billion indefinite delivery/indefinite quantity (IDIQ) contract to Aptive HTG to provide healthcare and professional consulting services that support VHA in providing seamless, high-quality, integrated, coordinated healthcare to Veterans nationwide. Integrity Management Services, Inc. (IntegrityM) is a member of the…
Artificial Intelligence (AI) applications are at our fingertips every day – think Siri, Alexa, Netflix recommendations, and spam filters. Most AI algorithms use large quantities of data to learn about human behavior (called machine learning). Machine learning is increasingly used in decision making – examples include criminal justice, credit/loans, recruitment, education, and clinical diagnosis. These automated…
IntegrityM is a wholehearted supporter of the current public effort to minimize the spread of COVID-19 through social distancing and self-isolation. We know that while these practices are good for public health – they aren’t always easy. Fortunately, the online world is stepping up to help us stay busy, engaged and connected within our own…
Leading Women-Owned Small Business IntegrityM was presented with the U.S. Women’s Chamber of Commerce “Stellar” Award. This category recognizes “exceptional contractors who have shown exemplary growth, quality, and are positioned as leaders within the contracting community.” The U.S. Women’s Chamber of Commerce unifies the collective strength of women in the U.S. economy, and the organization’s…
Leading women-owned small business Integrity Management Services, Inc. (IntegrityM), is pleased to announce that Swathi Young has joined the firm as Chief Technology Officer. In this role, Swathi will spearhead the delivery of innovative digital solutions for clients and optimize infrastructure for associated implementation, integration and operational processes. Swathi brings 20+ years of technology experience…
Integrity Management Services, Inc. (IntegrityM) has been awarded a competitive small business set-aside federal prime contract from the Centers for Medicare & Medicaid Services (CMS), Office of Financial Management, Division of Financial Audit and Resolution having responsibility for the financial oversight of cost-based Managed Care Organizations (MCOs). Under this five year contract, IntegrityM, along with…
One good way to measure the effectiveness and efficiency of a Special Investigative Unit (SIU) is to determine its return on investment (ROI). While some companies may conduct routine evaluations of their SIUs, one area that is hidden and thus difficult to measure is the existence of wasted investigative man-hours, or, what we call, investigative…
Working remotely allows people a certain amount of autonomy, but being less engaged with the day-to-day routines and culture of the office can reduce an employee’s productivity and sense of belonging. How do you know what’s too much or too little? It’s important to keep your remote team members in the loop without micromanaging them….
IntegrityM is honored to be recently named to the Virginia School Boards Association (VSBA) Business Honor Roll for the work they do in support of Fairfax County Public Schools (FCPS) through the IntegrityM Cares program. The VSBA Business Honor Roll is announced each spring as a way for school districts to show local businesses their appreciation…
IntegrityM is excited to announce that we’ve been nominated for a Greater Washington Good Business Award in the small business category, presented by the Northern Virginia Chamber of Commerce.These awards honor and celebrate the leadership of individuals, businesses, and nonprofits that serve as powerful champions for good in our community. From corporate social responsibility champions,…
A well-written healthcare fraud investigative report can help to identify and prevent improper payments – having a significant impact on individuals and organizations, including federal and state government agencies. The regulations and requirements that govern the healthcare industry are complicated, creating a long and technical process for investigating potential fraud, waste, and abuse. Investigative reports…
ALEXANDRIA, VA — Integrity Management Services, Inc. (IntegrityM), an Alexandria-based, women-owned small business, is proud to reach an exciting milestone this year – celebrating 10 years supporting program integrity efforts for federal and state government agencies and private sector organizations. IntegrityM is led by partners Nisha Shajahan, Cheryl Gordon, and Chris Coleman, who are committed…
When accidents or weather delays cause traffic to stall for miles, it’s easy to understand the appeal of working remotely. According to FlexJobs, more than 3.9 million Americans reported working from home occasionally or full-time in 2018, with healthcare among the top industries for telecommuting. In addition to specific licensures or qualifications, there are a…
According to the National Eye Institute, by 2050, the estimated number of people with age-related macular degeneration (AMD) in the United States is expected to more than double from 2.07 million to 5.44 million. With the influx of patients expected and healthcare expenditures nearing 18% of the U.S. gross domestic product (GDP) — an estimated…
IntegrityM to Present and Exhibit at HCCA Managed Care Compliance Conference IntegrityM is pleased to announce that it will present at the Health Care Compliance Association’s 2019 Managed Care Compliance Conference at 11 a.m. on January 28, 2019 in Lake Buena Vista, Florida. Conference attendees will also have an opportunity to meet the IntegrityM team…
Unless you’re living under a rock, you probably heard the news — Amazon is expanding and will make their new home (or part of it, rather) in what will now be known as National Landing. What effect will our new neighbors have in the region? While there are many positive impacts, those tasked with sourcing…
There are times, despite your best efforts, things may go wrong, impacting customer satisfaction. When conflict or uncomfortable situations arise, act swiftly to reduce tension and begin repairing your customer relationship using these best practices: Apologize. Regardless of who caused the issue step up and offer an apology. Acknowledge any oversights or mistakes, and focus…
Most businesses have two basic goals: to maintain profitability and to grow revenue. As simple as these goals are, some companies are so focused on growing new business pursuits, they tend to overlook the importance of keeping their current customers satisfied. Generating and retaining loyal, longtime customers should be a priority for every business. While some…
IntegrityM President and CEO Named Washington Business Journal 40 Under 40 Honoree Integrity Management Services Inc. (IntegrityM) President and CEO, Nisha Shajahan, has been named a Washington Business Journal (WBJ) 2018 40 Under 40 Honoree. A ceremony recognizing the honorees was held on June 26 at the PNC Diamond Club at Nationals Park. “Each honoree…
In 2016, there were more than 63,600 drug overdose deaths in the United States — this is more than three times the rate in 1999 according to a report from the National Center for Health Statistics (NCHS), part of the US Center for Disease Control and Prevention (CDC).i In a July 2017 report, The U.S….
IntegrityM Honored for Excellence in the Government Contracting Industry Integrity Management Services, Inc. (IntegrityM) is honored to announce it was selected as the winner of The Small and Emerging Contractors Advisory Forum (SECAF) 2018 Award of Excellence. The Award of Excellence highlights an organization that represents excellence within their community, the government contracting industry, and towards employees….
IntegrityM Honored for Excellence in the Government Contracting Industry IntegrityM today announced that it was selected as a finalist for the 10th Annual Small and Emerging Contractors Advisory Forum (SECAF) Awards. Winners will be announced at the SECAF Awards Gala on Thursday, May 10, 2018 at the Hilton McLean in Tysons Corner. 2018 finalists are named…
Medical coders often serve as the gatekeepers of compliance and quality for healthcare organizations. Errors and mistakes can result in denials, delayed payments, or even put an organization at risk for receiving improper payments. Coding can often involve a complex process and finding a coder with the right combination of skills can be difficult, especially…
Integrity Management Services Inc. (IntegrityM) is honored to announce our President/CEO, Nisha Shajahan, has been selected as a finalist for the 19th Annual Women In Technology (WIT) Leadership Awards. Annually, the Leadership Awards recognize and honor women professionals who have exemplified leadership while promoting the WIT mission of Advancing Women in Technology from the Classroom…
Integrity Management Services Inc. (IntegrityM) is pleased to announce that Jennifer Tryder, Program Director, and John Hapchuk, Healthcare Regulatory Consultant, have been selected to deliver their presentation at the Health Care Compliance Association’s (HCCA) 2018 Managed Care Compliance Conference. HCCA, a member-based association for compliance professionals in the healthcare provider field, was established in 1996….
Fighting fraud, waste, and abuse in health care programs is labor intensive often requiring multiple experts including but not limited to data analysts and statisticians, certified coders, clinicians, auditors and fraud investigators. According to The National Health Expenditure Accounts (NHEA), U.S. health care expenditures rose by 2.8 percent in 2015 accounting for approximately 17.8 percent…
Integrity Management Services, Inc. (IntegrityM) has been awarded a competitive total set-aside prime Federal contract from Health Resources and Services Administration (HRSA) under the Department of Health and Human Services (HHS). HRSA is an operating division of HHS and is the primary Federal agency for improving access to health care services for people who are uninsured,…
Integrity Management Services Inc. (IntegrityM) is pleased to announce its participation as an exhibitor at the NHCAA Institute for Health Care Fraud Prevention Anti-Fraud Expo held in conjunction with the 2017 Annual Training Conference (ATC) in Orlando, Florida. The conference will be held at the Rosen Shingle Creek from November 14-17, 2017. During the NHCAA…
The key to successfully harnessing the power of data in healthcare is to analyze, interpret, and share the results in a way that is meaningful and effective for decision makers. Those located at the front lines — healthcare data analysts — play a central role in this process. As the healthcare industry rapidly changes, data…
Integrity Management Services, Inc. (IntegrityM) is pleased to announce that Didem Egemen, statistician, has been selected to deliver her abstract at the INFORMS 2017 Annual Meeting. INFORMS — the Institute for Operations Research and the Management Sciences — is the world’s largest professional association dedicated to and promoting best practices and advances in operations research,…
With over 2 billion Medicare claims available for analysis since 2006, the term “Big Data” has no better application than in the health care industry. The opportunity for meaningful analyses resulting from big data is limitless. However, finding the best method for combing through Medicare claims data in an efficient manner can be tricky since…
Organizations across the health care program integrity industry are using analytic solutions for fraud detection and prevention that intake and analyze data to signal the threat of fraud. These solutions can process huge amounts of data from multiple sources and remove much of the human element of potential fraud detection. When we think about these…
Integrity Management Services Inc. (IntegrityM) is pleased to announce its participation as an exhibitor at the 33rd Annual National Association for Medicaid Program Integrity (NAMPI) 2017 Conference in Miami, Florida. The conference will be held at the Loews Miami Hotel from August 6-9, 2017. During the NAMPI 2017 Conference, we will be available to introduce…
Healthcare Fraud Investigators provide a valuable resource in the fraud analysis process. They perform in-depth evaluation and analysis of potential fraud cases and requests for information using claims and other sources of data. One method for gathering information during an investigation is performing interviews. Along with analysis of records and other data, conducting fraud investigation…
Sarah Langford of Integrity Management Services, Inc. (IntegrityM) will present an overview of bias in fraud detection and prevention systems, providing insight on the points at which bias can be introduced and how to identify and prevent it. This informative and interactive presentation will take place during the Financial Intelligence & Information Sharing Working Group…
Telehealth is expanding rapidly and transforming healthcare. According to the Medicare Payment Advisory Commission, the number of telehealth visits grew by over 500 percent from 2008 to 2014. Additionally, many commercial insurers cover — and many health systems offer — a variety of telehealth services. The industry has seen impressive advancements in telehealth technology, and…
Integrity Management Services, Inc. (IntegrityM) is pleased to announce its achievement of International Organization for Standardization (ISO) 9001:2015 certification. ISO 9001:2015 certification establishes the criteria for quality management principles, including a strong customer focus, commitment of executive management, implementation of consistent business processes and continuous improvement. IntegrityM’s quality management system was assessed by Performance Review…
IntegrityM is honored to announce that it was selected as the 2017 Small Business Administration (SBA) Washington Metropolitan Area District Office (WMADO) Small Business Subcontractor of the Year. SBA’s small business awards program recognizes small business owners who have achieved notable success while also making valuable contributions to their community. SBA WMADO named additional honorees…
Federally Qualified Health Centers (FQHCs) provide primary care services to millions of people each year with limited access to care. Medicare Part B has covered FQHC services at certified FQHCs since 1991. They are an important and very unique part of the Medicare and Medicaid benefits with specific billing and payment rules that can get…
Integrity Management Services, Inc. (IntegrityM) is pleased to announce it has been appraised at level 3 of the CMMI Institute’s Capability Maturity Model Integration (CMMI)®. The appraisal was performed by Acme Process Group. CMMI is a capability improvement framework that provides organizations with the essential elements of effective processes that ultimately improve their performance. An…
IntegrityM Lauded for its Success in the Government Contracting Industry IntegrityM today announced that it was selected as a finalist for the 9th Annual Small and Emerging Contractors Advisory Forum (SECAF) Awards. Winners will be announced at the SECAF Awards Gala on Tuesday, May 9, 2017 at the Hilton McLean in Tysons Corner. The commemorative…
When performed correctly, statistically valid sampling and extrapolation can be a powerful tool, allowing for the effective use of audit and investigative resources. Statistically valid sampling allows organizations to collect information about a particular universe for a relatively low cost. Rather than incurring the time and expense of reviewing the entire universe, the conclusions drawn…
Constructing a solid medical review team requires the successful networking, staffing, management, and ongoing support of the clinicians and the support team. The Significance of a Solid Team Medical review is the clinical review of medical records and supporting data in order to provide claims determinations and ensure that payment is made only for services…
Healthcare fraud very seldom happens in a vacuum. Therefore, data matching — the ability to identify, match, and merge records that correspond to the same entities — is essential to healthcare data analysis. Using The NPPES Database For Data Matching The Centers for Medicare & Medicaid Services issues a unique identification number called a national…
Medicare and other health plans have a variety of tools at their disposal to prevent and identify improper payments. The tools can differ depending on whether they are applied before claims are paid (prepayment review), or after claims are paid (postpayment review). Pre and postpayment reviews are both important program integrity strategies, and can make…
In fiscal year (FY) 2015, the error rate for the Medicare fee-for-service (FFS) program was 12.1 percent, or $43.3 billion. This result is an improvement over FY 2014, in which Medicare FFS had an improper payment rate of 12.7 percent, or $45.8 billion. Identifying Medicare overpayments is no easy task. The Medicare program is large…
Paulo Macedo and Sewit Araia of Integrity Management Services (IntegrityM) will present an overview of data analytics methods used in fraud detection, giving users a greater confidence to identify patterns of behavior and an in-depth understanding of the algorithm behind predictive modeling. This interactive and informative workshop will take place during The NHCAA’s Annual Training…
Each year, the Federal Government makes billions of dollars in improper payments. Improper payments can take the form of overpayments, payments to the wrong person, or payments for the wrong reason. Two examples of improper payments include the Federal Government paying $180 million to 20,000 dead individuals over a three-year period, as well as paying…
What if there was a healthcare data analysis solution that could save you a significant amount of time in the sampling and extrapolation process, resulting in substantial cost savings, and therefore greatly increasing your return on every dollar invested into this process? More results with less time and costs! Manually performing sampling and extrapolation can…
Integrity Management Services, Inc. (IntegrityM) is proud to announce we have received our SWaM Certification from the Commonwealth of Virginia Department of Minority Business Enterprise (DMBE). The Small, Women-owned, and Minority-owned Business (SWaM) certification program is a state program of the Commonwealth of Virginia. The purpose is to enhance procurement opportunities for SWaM businesses participating…
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…
IntegrityM is proud to announce that, out of more than 100 submissions, they have been selected as a Finalist for the 2016 Federal Health IT Challenge. The 2016 Federal Health IT Challenge was open to small businesses, university students, and individuals who had an innovative solution in Federal Health IT to address topics such as Fraud, Waste…
IntegrityM is pleased to announce promotions within its executive team. “This is an incredibly exciting time for IntegrityM,” said Nisha Shajahan, President and CEO, IntegrityM. “I’m thrilled that we had talented leaders that allowed us to make these changes as we continue to expand our presence.” Natasha Williams, previously Vice President of Operations, has been…
Integrity Management Services, Inc. (IntegrityM) is happy to announce that Dr. Paulo Macedo has been selected to speak at the 2016 SAS Global Forum in Las Vegas from April 18 – 21. Dr. Macedo is an invited speaker at the SAS Global Forum 2016. SAS Global Forum is the world’s largest analytics conference, attended by…
Integrity Management Services, Inc. – IntegrityM, a leading provider of program integrity and compliance solutions to federal and state agencies, is excited to announce that it is now a Woman Owned Small Business (WOSB). Established in 2009 initially as a subsidiary of Strategic Management Systems, IntegrityM has continued to expand its capabilities and services to…
It is important for every industry to have a framework of quality standards by which to measure performance and to establish credibility. Most people have heard of the Yellow Book, or The Generally Accepted Government Auditing Standards, that is used by audit organizations. Evaluation work does not have a well-known equivalent and organizations are often…
In 2015, the Veterans Affairs (VA) Health Care achieved a distinction held by two other large Federal health care programs – Medicare and Medicaid – that of being designated a Government Accountability Office (GAO) high risk program. VA Health Care was added to the GAO High Risk List in response to its problems providing adequate…
The HHS OIG released its Work Plan for FY 2016 on November 2nd. The Work Plan outlines audits, evaluations, and other activities OIG is conducting or plans to conduct in the coming fiscal year. Much of the planned work for FY 2016 focuses on cut and dry payment reviews with the goal of identifying and…
International Fraud Awareness Week kicks off Nov. 15, 2015 worldwide [Alexandria, Virginia]– Fraud costs organizations worldwide an estimated 5 percent of their annual revenues, according to a study conducted by the Association of Certified Fraud Examiners (ACFE). If applied to the 2014 estimated Gross World Product, this translates to a potential projected global fraud loss…
On September 25, 2015, the Centers for Medicare & Medicaid Services (CMS) awarded the new Trusted Third Party (TTP) contract to Computer Sciences Corporation (CSC), an industry leader of next-generation technology solutions. Under the contract, CSC will support the Healthcare Fraud Prevention Partnership (HFPP) as it continues to mature in operations and meaningful information exchange….
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…
Section 2703 of the Affordable Care Act created an optional Medicaid State Plan benefit – Health Homes – to coordinate care for individuals who have Medicaid and have: 2 or more chronic conditions; 1 chronic condition and are at risk for a second; or 1 serious and persistent mental health condition. Chronic conditions include substance…
The Government Accountability Office (GAO) made headlines recently when sharing news that 11 of 12 fictitious applicants obtained coverage for health insurance through the Federal marketplace. GAO targeted the Federal marketplace with secret shopping – constructing fictitious applicants who should not have received health insurance. The secret shopping applicants provided invalid Social Security information or…
In May 2009, the U.S. Department of Health and Human Services Office of Inspector General (OIG) released a report regarding Medicaid managed care encounter data. The OIG found all 40 States with capitated managed care reported collecting encounter data from their managed care plans. However; 15 States did not include encounter data in their Medicaid Statistical…
Medicare ambulance claims, just like everything involved with Medicare, must meet certain requirements to be considered valid ambulance transport claims. The main factor is the transport must be considered “medically necessary” under Federal Law. To do this, two specific criteria must be met: The use of other transportation methods is contraindicated by the condition of…
The No Wrong Door (NWD) system is intended to streamline access to long-term services and support (LTSS) options for older adults and individuals living with disabilities. NWD grants are collectively overseen by the Administration for Community Living, the Centers for Medicare & Medicaid Services, and the Veterans Health Administration. Without NWD, finding the right…
In May 2015, the U.S. Department of Health and Human Services Office of Inspector General (OIG) issued a report finding all claims for the provider under review failed to support medical necessity. OIG concluded virtually all payments the provider received were unallowable. Why were all payments not identified as unallowable? OIG used a sample and…
Since the late 20th to early 21st century, reports such as “To Err is Human” by the Institute of Medicine have been published and have advocated the adoption of electronic health records (EHRs). EHRs offer tools to mitigate human error, be a medium to share personal medical records securely across the country, establish electronic communications…
OIG has just released the last in a series of four Medicaid dental fraud reports. The reports identified dentists and orthodontists with questionable billing practices in New York, Louisiana, Indiana, and California. These reports are just one part of OIG’s multi-faceted approach to combat dental fraud. The agency also has ongoing audits of Medicaid dental…
The U.S. Department of Health and Human Services Office of Inspector General (OIG) recently released a data chart offering fiscal year (FY) 2014 statistical data for the Medicaid Fraud Control Units. For those of you unfamiliar with Medicaid Fraud Control Units (MFCU), the MFCUs are: single identifiable entities of State government that conduct a Statewide…
In May 2014, the Government Accountability Office (GAO) released a report calling for increased oversight of Medicaid managed care spending (the report can be found here). GAO reported that “Most state and federal program integrity officials we interviewed told us that they did not closely examine Medicaid managed care payments, but instead primarily focused their…
The purpose of this paper is to offer a technique to more clearly and fully describe healthcare errors detected in audits, which can lead to improved return on investment (ROI) for healthcare audits. A clear and complete description of all identified errors in a healthcare audit report will help assure that all readers of the…
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…
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…
A few years ago, one of our team members served as the masters of ceremonies at a training program for individuals interested in government evaluation. He periodically mentioned the Blue Book in the transitions between the various presenters. Later, during a break, numerous people asked him about this Blue Book. It was a bit surprising….
On March 6, 2015, the U.S. Department of Health and Human Services Office of Inspector General (OIG) released the latest in a series of reports looking at hospitals’ billing and Medicare paying for Kwashiorkor. For those new to Kwashiorkor, Kwashiorkor is a form of severe protein malnutrition that generally affects children living in tropical and…
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