Benefit/Program Integrity
Slider

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 provider types:

Ryan Farrell, CFE
Principal
rfarrell@mslc.com

512.342.0800

Provider Enrollment

Read More

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

Read More

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

Read More

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

Read More

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

Read More

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

Read More

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

Read More

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 and maximum allowable cost (MAC) list audits.
  • Plan design accuracy audits.
  • Invoice reconciliation audits.
  • Pricing guarantee accuracy audits.
  • Average wholesale price accuracy audit.

Prescription Drug Benefit Oversight

Read More

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.

Government Employee and Retiree Health Benefit Plan

Read More

Our audits of third party administrators (TPAs) of government employee and retiree health benefit plans include testing of the TPA claims adjudication processes, clinical functions, internal audit functions, and compliance with contract terms and performance guarantees. Our services include:

  • Develop statistically valid claim sampling plan.
  • Perform testing of claims for various attributes such as proper payment according to the plan benefit design and the provider contract, correct accumulation of benefits, and proper coordination of benefits.
  • Perform testing of targeted claim samples such as duplicate claims, claims paid for excluded services, claims paid for employees or retirees not enrolled in the plan for the date of service, etc.
  • Analyze policies, procedures, and processes surrounding clinical functions for gaps in comparison to state laws and regulations, contractual obligations, and industry standards.
  • Perform testing of clinical functions to ensure adherence to policies, procedures, and processes.
  • Analyze internal audit processes for gaps in comparison to contractual obligations and industry standards.
  • Analyze internal audit findings for payments that may be due to the governmental agency served.
  • Ensure compliance with contract terms.
  • Ensure compliance with performance guarantees and calculate damages that may be due.

Child Nutrition Programs

Read More

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.