Program Integrity
HMS has been assisting state Medicaid programs with program integrity-related projects for many years, working primarily with Medicaid Program Integrity units and Third Party Liability units.
Through provisions contained in the Deficit Reduction Act of 2005, CMS was charged with creating and implementing a nationwide Medicaid Integrity Program. This increase in federal scrutiny amplifies Medicaid entities' responsibilities to conduct due diligence in order to detect, recover, and prevent inappropriate Medicaid payments. CMS also maintains Program Integrity guidelines for Medicare and Part D plans.
HMS has a track record of mining large quantities of data to identify erroneous payments or overpayments. Using our enormous warehouse of claims data, HMS can develop and implement large-scale analysis, identification, validation, and recovery projects to help plans maximize ROI for their program integrity efforts.
HMS offers a variety of competencies to assist plans with their program integrity initiatives:
- A storehouse of historical paid claims data for our current clients
- Data mining and analysis capabilities
- Practical experience with individual states' claim and eligibility data, payment policies and practices, and provider communities
- In-place payment recovery protocols (including billing, provider recoupments, and lockbox arrangements)
- Established relationships with subcontractors expert in financial and clinical audits
- Over 20 years of experience identifying, validating, and recovering overpayments