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….
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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…
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 healthcare price transparency, problems that have affected millions of patients for years. Surprise billing occurs…
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 diagnoses, payers are confronting an emerging fraud scheme that demands both advanced data…
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 can inform policy development and updates. By making complex data accessible and actionable, these…
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…
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Combating Fraud with Data Analytics: The Fight for Healthcare Fraud Continues
News on an addiction treatment facility operator caught paying $2.9M in kickbacks underscores the urgent need for robust fraud prevention. The fight for healthcare integrity continues at IntegrityM. Here, we unlock the power of data analytics to transform insights into impactful actions. Join us in shaping the future of healthcare integrity.
“Outsized Returns” in Combating Healthcare Fraud!
Last week, the U.S. Department of Justice presented several cases highlighting how “the department’s investment in data analytics produces outsized returns” in its fight against healthcare fraud. Learn more about the 2024 National Enforcement Action. At Integrity Management Services, Inc., we are honored to support the government in its relentless efforts to combat healthcare fraud, waste, and…
Signs of Fraud in Payment Arrangements!
Fraud in Medicare Advantage often operates under the radar, but relationships or subtle patterns can reveal its presence. To uphold program integrity, look beyond obvious data anomalies and consider these critical warning signs: Unusual referral patterns between providers/suppliers Frequent turnover of enrollment agents Unexpected spikes in plan-switching behavior At IntegrityM, we recognize that effective fraud…
