AI and machine learning are increasingly central to fraud analytics in complex, highly regulated environments. As adoption accelerates, much of the public conversation focuses on algorithms, new architectures, improved accuracy metrics, and automation at scale. While these advances matter, real-world experience shows that algorithms themselves are rarely the limiting factor. Today’s machine learning algorithms are already highly capable….
Expertise
Subrecipient Monitoring That Survives Single Audit– Part 1 of 2
Effective subrecipient monitoring is essential for any pass-through entity that administers federal funds. To “survive” a Single Audit (the comprehensive annual audit for entities expending significant federal funds), organizations must go beyond minimal oversight. They need a structured approach that satisfies Uniform Guidance requirements and stands up to auditor scrutiny. This post outlines three pillars of audit-proof…
Subrecipient Monitoring That Survives Single Audit– Part 2 of 2
In continuation of our Subrecipient Monitoring series we continue to explore the remaining Pillars. Pillar 2 – Verification: Trust But Verify Subrecipient Compliance Once subawards are made (and risk-tiering is in place), the mantra is “trust but verify.” Verification in subrecipient monitoring means continually checking that subrecipients remain in compliance and on track to meet…
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: Strong policies not only meet compliance requirements but also create consistency across the organization. They help staff make decisions…
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 federal funding bear a critical responsibility: managing taxpayer dollars with integrity,…
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 utilization review, transforming complex healthcare data into outcomes that are accurate, compliant, and defensible….
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 resources while maintaining statistical integrity when applied properly. This approach…
What you need to know about the 2021 Open Payments Program Expansion
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)…
Five Best Practices for Repairing Your Customer Relationship (Pt 2)
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…
Five Customer Service Best Practices to Maximize Retention (Pt 1)
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…
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…
Using the CIGIE Quality Standards for Inspection and Evaluation
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…
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…
No Wrong Door LTSS Program Evaluations and Planning
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…
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…
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…
