Eligibility Integrity
Eligibility Integrity

Eligibility Integrity Services

Incorrect eligibility decisions and/or inaccurate data can result in significant financial losses to federal, state, or local health and human services benefit programs. The Centers for Medicare & Medicaid Services (CMS), the Health and Human Services Office of the Inspector General (HHS-OIG), and other benefit entities consider eligibility to be a top program integrity priority for benefit programs, from the application process to continued analysis of membership rolls and associated data. Nationwide, the eligibility of participants in any benefit program is an essential consideration for payers and stakeholders: are you paying for services for individuals who are not eligible for those services, thereby further reducing the scarce funds available for governmental services? Do membership files reveal duplicate members or other issues that generate questions with respect to the accuracy and completeness of the underlying data?

Advising Health and Human Services Agencies

Myers and Stauffer has extensive experience with the complex eligibility puzzle – advising health and human services agencies on eligibility system issues, eligibility determination processes, the data used to determine or verify eligibility, and the resulting data maintained within the various systems. We have performed eligibility compliance reviews, eligibility audits, and eligibility data analyses for federal, state, and local government clients for almost 20 years. Our experience includes:

  • Supporting government payers with payer-specific eligibility compliance initiatives. On the national level, we perform Medicaid and Children’s Health Insurance Program (CHIP) member compliance reviews as part of CMS’ national Payment Error Rate Measurement (PERM) Eligibility Review Contractor (ERC) team. PERM is an annual review required by the Improper Payments Information Act (IPIA) of 2002, and amended by the Improper Payments Elimination and Recovery Act of 2010 (IPERA) and the Improper Payments Elimination and Recovery Improvement Act of 2012 (IPERIA).
  • Eligibility data quality improvement initiatives, including identification of potentially duplicative member records.
  • Investigating eligibility fraud, waste, and abuse. Specifically, identifying and investigating potential member/recipient fraud.
  • Analysis of employee benefit and other human service benefit program eligibility data and determinations.
  • Through our federal and state experiences, we have a thorough understanding of federal facilitated marketplace and state-based marketplaces.
  • Our expertise extends to non-Medicaid state agencies that determine eligibility for Medicaid through express lane eligibility, as well as to understanding eligibility for numerous other government payers.

Our eligibility integrity services include:

Emily Wale, CPA, CFE


Eligibility Compliance

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We offer specialized expertise in eligibility compliance based upon federal, state, and/or payer-specific eligibility policies. Whether the eligibility benefit relates to health care, food assistance, child care, or other human service programs, our analytical approach to understanding the nuances of the eligibility process, eligibility data, and the functions of eligibility systems is critical to assessing and identifying strengths and weaknesses in operations and systems. Specifically, our team has the qualifications necessary to:

  • Access and utilize information across eligibility system platforms.
  • Prepare or review sampling plans, stratify data, and select and validate samples.
  • Prepare and submit required reports and updates.
  • Collect and prepare eligibility records and source documentation.
  • Work with data obtained from numerous sources including the state’s Department of Labor, the Social Security Administration, the Public Assistance Reporting Information System (PARIS), and other payer-specific sources.
  • Audit, track, and manage cases selected for review.
  • Analyze membership data to identify trends, data anomalies, and/or potentially duplicative records.
  • Perform detailed, systematic analysis of member eligibility records to ensure members are eligible based upon payer-specific policies.
  • Identify errors resulting from eligibility compliance issues.
  • Calculate error and monetary outcomes.
  • Prepare or review corrective action plans, observations, and recommendations to improve eligibility policies, procedures, and systems.
  • Interact with stakeholders.
  • Assist with difference resolution, reconsiderations, and appeals.

Member Fraud, Waste, and Abuse Investigations

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We assist benefit programs with the detection and investigation of potential fraudulent and erroneous administrative payments as a result of newly identified member information. Our member audit expertise includes identifying the period of ineligibility, error causes, and requesting necessary member overpayment recovery. Specifically, our team has the qualifications necessary to:

  • Perform member and dependent investigations using newly discovered information impacting the member’s eligibility for the benefits being provided. Investigations are conducted using program guidelines, procedures, and established service policies.
  • Perform data analytics, including fee-for-service and managed care member record analysis and recovery.
  • Interact with benefit members, clients, third party collateral information sources, as necessary, to obtain missing or outdated information to complete and supplement audits.
  • Audit payment systems to enhance program management by auditing point of service fees and managed care service fees. We will identify and calculate payment errors and determine member enrollment patterns or trends.
  • Assist with appeal resolution as a result of any audit, providing documentation support, data protection, audit analyses, and submission of audit summaries.
  • Perform comprehensive evaluation of program post payment process to address issues such as unnecessary service receipt, along with identification of outliers that may be a result of potential fraud, waste, or abuse.