Eligibility Integrity

Incorrect eligibility decisions can result in significant financial losses to your benefit program. As such, both the Centers for Medicare & Medicaid Services (CMS) and the Health and Human Services Office of the Inspector General (HHS-OIG) consider eligibility to be a top program integrity priority for states’ health programs, from online application to continued analysis of membership rolls. Nationwide, the eligibility of participants in any health 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 other individuals who may need services?

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

  • Helping government health payers with payer-specific eligibility compliance initiatives,
  • Eligibility quality improvement initiatives.
  • Investigating eligibility fraud, waste, and abuse. Specifically, on the national level, we perform eligibility compliance reviews as a part of CMS’ national Eligibility Review Contractor team.
  • 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:

Charles Smith III, CPA


Eligibility Compliance

Read More

We offer specialized expertise in eligibility compliance based upon federal, state, or payer-specific eligibility policies. 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 various eligibility system platforms.
  • Prepare sampling plans, stratify data, and select and validate samples.
  • Prepare and submit all CMS-required reports and updates.
  • Collect and prepare eligibility records and source documentation.
  • Work with data obtained from numerous sources including the Federal Data Services Hub, the 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.
  • Perform detailed, systematic analysis of member eligibility records to ensure eligibility system determinations are accurate based upon federal and state policies, including state plans, state plan amendments, administrative code, CMS-approved waivers, verification plans, state medical assistance policies, and other payer-specific policies.
  • Identify and calculate payment errors resulting from eligibility compliance issues.
  • Prepare corrective action plans, observations, and recommendations to improve eligibility policies, procedures, and systems.
  • Interact with stakeholders.
  • Assist with difference resolution, reconsiderations, and appeals.

Eligibility Integrity

Read More

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

  • Perform member and dependent eligibility audits.
  • Perform eligibility data analytics, including fee-for-service and managed care member record analysis and recovery.
  • Audit member enrollment, reviewing and confirming member eligibility based on program guidelines, procedures, and established service policies.
  • Interact with program 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 can 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.