Benefit/Program Integrity
Benefit/Program Integrity

BPI Loss Prevention, Auditing, and Recovery Services

Our benefit/program integrity (BPI) team is focused on protecting the integrity of Medicaid and Medicare payments, processes, and systems. Myers and Stauffer is able to assist our clients with the development, maintenance, and execution of organizational compliance plans to hold stakeholders accountable. We specialize in providing risk assessment, error rate measurement, loss prevention, and specialized auditing services to support public health care and social service agencies.

The BPI loss prevention, auditing, and recovery services have prevented unnecessary program expenditures, identified millions of dollars in inappropriate payments, and evaluated corrective action initiatives to ensure the future integrity of the programs. We have performed eligibility audits and analyses, and used data analytics to help our client’s direct scarce health care funding to achieve their health care objectives.

Our benefit/program integrity experience includes these program areas:

Ryan Farrell, CFE


Telehealth Audit Support

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In response to the COVID-19 pandemic, the expansion of telehealth has fundamentally changed provider-patient interactions. While relaxed telehealth regulations give health care providers opportunity to improve patient care, they also make room for pervasive fraud, waste, and abuse. The sudden and pronounced increase in telemedicine services driven by the pandemic comes with both risk and reward. 

The primary reward is increased access to care across various populations nationally. As fostered efficiencies integrate into the health care landscape, decreased costs also stand out as a potential reward; however, reaping these benefits requires both anticipating and overcoming challenges. The lack of provider knowledge about telehealth services can lead to improper billings alongside decreased efficiency in oversight and support.

Our strengths include: 

  • Breadth of clinical and coding knowledge and
  • Government payer and health plan data subject matter
  • No conflicts with providers or health plans.

Myers and Stauffer can help you recognize the fraud schemes that use telemedicine services, either directly through the service itself, or indirectly by using telehealth to assist in perpetrating other fraudulent activities. We can also identify cases of waste and abuse that, while not fraudulent, are inappropriate misuse of scarce resources.

Our review of telemedicine services can identify the “bad actors” in your provider population and help you recover overpayments deriving from fraudulent claims that are costly to state and federal programs, as well as taxpayers. These overpayments are excessive funds that can and should be spent on legitimate health care services.

Telehealth fraud, waste, and abuse can take different forms, ranging from false claims based on inaccurate coding and billing, to complex kickback schemes. The following are a few risk areas that are likely to invite scrutiny:

  • Up-Coding Time and Complexity. The Centers for Medicare & Medicaid Services (CMS) recently stated that it would closely monitor reimbursement requests to detect instances where providers inflate the time spent rendering telemedicine services. Failure to accurately bill for the precise time spent on telemedicine services and correctly account for the complexity of those services, with the intention to increase reimbursements, could result in False Claims Act liability.
  • Misrepresenting the Virtual Space Provided. Medicare now reimburses for several types of virtual interactions, including telemedicine visits, virtual check-ins, telephone visits, and e-visits. It is critical that providers understand the requirements for each type of interaction, which Current Procedural Terminology codes apply, and how to bill for them.
  • Billing for Services not Rendered. Submitting claims for services not provided, or not provided effectively, poses a significant enforcement risk. Even if a provider attempts to provide services in good faith, but technical difficulties prevent them from doing so, services should not be billed.
  • There have been prosecutions of kickback schemes executed via telehealth. The defendants allegedly employed a variety of marketing tactics to make unsolicited contact with beneficiaries and ultimately prescribed or referred them for unnecessary genetic testing, prescription medications, or durable medical equipment, for which the defendants received kickbacks.
  • Telemedicine Waste. If a telemedicine appointment occurs, but the patient clearly cannot fully see, hear, or otherwise benefit from the appointment, the services could be considered wasteful.

Provider Enrollment

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Maintaining compliance with federal regulations while developing an effective provider enrollment process is challenging for any program integrity department. Our team will meet with you to discuss where you are now with provider enrollment integrity and compliance, where your program should be, and how to get you where you need to be. Our provider enrollment services include:

  • Protect the managed care environment.
  • Provider compliance.
  • Provider lock in.

Predictive and Data Analytics

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Analytics is one of the most powerful tools you can use to identify vulnerabilities in your program and assist you with fighting health care fraud, waste, and abuse. Myers and Stauffer will help you move beyond statistics and historical findings to providing a best practice assessment of what may happen in the future. Our services include:

  • Advanced algorithms developed specifically for your state Medicaid program.
  • Forensic analyses of claims processing systems.
  • Employee benefit/Medicaid/CHIP/workers compensation/pharmacy benefit manager (PBM) claims data analytics and audits.
  • Medicaid recovery audit contractor (RAC) services.

Developing and Maintaining an Effective Audit Program

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Myers and Stauffer performs audits of health care providers, managed care organizations, and pharmacy benefit managers on behalf of state Medicaid programs and federal health care programs. Our firm has developed a unique understanding and appreciation of the complexity of the health care industry, including anti-kickback, self-referral, safe harbor regulations, Medicare and Medicaid reimbursement, corporate integrity agreements and compliance plans, false claims actions, and other fraud and abuse issues. Services include:

  • Quality improvement initiatives.
  • Service utilization analyses.
  • Specialized program integrity auditing and consulting.
  • Quality of care audits.
  • Pre- and post-pay claims audits – clinical/financial.
  • Women Infants and Children (WIC)/Supplemental Nutrition Assistance Program (SNAP) audits/oversight.
  • Alternative payment model compliance/auditing.
  • Software modules for surveillance and utilization review subsystem (SURS), fraud and abuse detection services (FADS), and case tracking.
  • Promoting Interoperability Program (formerly EHR) Incentive Payment audits and consulting.
  • Claims coding audits.

Vendor Contract Compliance

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Ensuring vendor contract compliance is an important component of a healthy Medicaid and Medicare program. Our staff of experts can analyze operations and conduct performance audits to answer questions critical to your success. Our contract compliance services include:

  • Provider, member, and claims risk assessments.
  • Non-emergency medical transportation (NEMT) broker and other state vendor compliance.
  • Payment system/claims processing accuracy.
  • Litigation support.
  • Review of managed care organizations, fiscal agents, and PBMs.

External Stakeholder Review Response

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The Centers for Medicare & Medicaid’s (CMS) state program integrity reviews and HHS-OIG audits can have significant negative financial impact on state Medicaid programs if not handled properly. Myers and Stauffer has significant experience assisting our clients with external stakeholder reviews. Negative financial impacts can be minimized if you know where to look and have the resources to perform self-audits. Our stakeholder review services include:

  • Provider claims analyses and audits.
  • Coordination of audit response process.
  • Development of response documents.

Effective Case Management

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An effective case tracking system is essential to enable staff to work efficiently and productively, while ensuring accurate and timely reporting capabilities and response to requests from stakeholders. Myers and Stauffer assists states in designing and/or adopting a new case tracking system. Our services include:

  • Modular case tracking system configured to the state’s needs.
  • Flexible, easy to learn reporting capabilities.
  • Integrated workflows developed with program integrity expertise.

Pharmacy Benefit Manager Audit Services

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Not only does Myers and Stauffer have significant experience performing financial, benefit design, and compliance audits of every large PBM in the industry, but our professionals also have extensive experience assisting our government clients with performing prescription claims audits, auditing clinical compliance with formulary and prior-authorization requirements, performing pharmacy benefit program integrity data analysis and audits, and conducting policy and procedures reviews of coverage determinations, appeals, and grievances. Our PBM services include:

  • Rebate audits.
  • Price basis (average wholesale price [AWP], actual acquisition cost [AAC], wholesale acquisition cost [WAC], and National Average Drug Acquisition Cost [NADAC]), and maximum allowable cost (MAC) list audits.
  • Claim adjudication audits.
  • Plan design accuracy audits.
  • Invoice reconciliation audits.
  • Pricing guarantee accuracy audits.
  • Performance guarantee audits.
  • Clinical program, formulary and utilization management adherence audits.
  • Spread pricing analysis.
  • PBM operational reviews.

Prescription Drug Benefit Oversight

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The rising cost of prescription medication is an issue that affects nearly every family in this country. What was once a difficult burden to bear, has now become a national emergency with skyrocketing prices and costs keeping many Americans from being able to afford the life-saving medications they need to survive. Our pharmaceutical program integrity experts will help your organization control costs, detect fraud, and ensure that Medicaid recipients receive the medication they require. Our services include:

  • Utilization reviews.
  • Billing compliance.
  • PBM compliance.
  • Fraud, waste, and abuse detection.
  • Controlled substance management.
  • J and Q code oversight.
  • 340B compliance.
  • Member lock-in.

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State and local governments need an experienced consultant with health care claims, compliance auditing, and benefit program expertise to assist with contractor compliance and provide processes to properly monitor employee benefit programs. Myers and Stauffer provides comprehensive audit services of Third Party Administrators (TPAs) and Pharmacy Benefit Managers (PBMs). These audits ensure the administrators of the employee benefit plan are performing according to their contract, meeting performance guarantees, adjudicating claims consistent with the plan benefit design, and rebates and other credits are appropriately remitted. Our services related to benefit administrator audits can be tailored to your unique needs, concerns, and budgetary constraints and include:

  • Third-Party Administrator (TPA) Audits
  • Pharmacy Benefit Manager (PBM) Audits
  • Provider Audits
  • Member and Dependent Eligibility Audits

Learn more about our Government Employee
and Retiree Benefit Plan Audit Services

Child Nutrition Programs

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Ensuring vendor regulatory compliance is a critical component to the successful performance of the Child and Adult Care Food Program (CACFP). The CACFP is a federally-funded, state-administered program to provide healthy meals and snacks to eligible children and adults in day care settings, in line with the U.S. Department of Agriculture’s (USDA) nutritional standards. The program goal is to improve and maintain the health and nutrition status of children and adults in care while promoting the development of good nutrition habits. Myers and Stauffer performs administrative reviews of the CACFP participating sponsors to ensure compliance with provider payment, participant eligibility, meal patterns/nutrition requirements, record keeping, and other program requirements.

Services include:

  • Pre-review preparatory work such as pulling claims, sponsor applications, and prior sponsor reviews.
  • Entrance and exit conferences with the sponsor designee, typically at the sponsor location.
  • Review of all required CACFP documentation and records to ensure compliance with USDA and state agency requirements.
  • On-site sponsor facility review to assess real-time regulatory compliance.
  • On-site technical assistance in regard to complying with program requirements and maintaining appropriate documentation.
  • Multi-level internal quality review process for all final sponsor administrative review reports.
  • Availability and expertise to testify during sponsor appeal hearings.
  • Assistance to update and/or refine administrative review tools to reflect regulatory requirements, and to promote efficiencies, accuracy, and clear findings documentation.