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…
Investigations
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 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 dollars, amniotic products are becoming an increasingly attractive target for unscrupulous providers and…
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….
Medicare’s $60 Billion Challenge
Medicare loses an estimated $60 billion annually to fraud, waste, and abuse (FWA), a serious drain on critical health resources that directly affects the care and well-being of millions of beneficiaries. These losses not only compromise the integrity of the program but also erode public trust in one of our nation’s most essential public health…
Exposing Hidden Risks: A Strategic Approach to FWA in Medicare Advantage
Medicare Advantage (MA) has reshaped healthcare coverage for beneficiaries, offering comprehensive benefits through private insurers. However, the program’s expansion has also introduced complex challenges, notably fraud, waste, and abuse (FWA) that threaten its integrity and the well-being of beneficiaries. The Challenge Recent investigations have uncovered concerning practices within the MA landscape. Some Medicare Advantage Organizations…
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…
How it Works: Health Insurance Fraud Investigation
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…
Four Schemes to be Wary of Amid Soaring COVID-19 Fraud Reports
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,…
Avoid “Investigative Leakage” for More Effective and Efficient Healthcare Fraud Investigations
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…
Comparative Billing Reports: A Valuable Tool for Outreach and Education
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….
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…
Evaluations Have Standards Too: An Introduction to Government Evaluation Standards
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….
