Managed Care Program Integrity
We provide Medicaid managed care program integrity services that help state agencies strengthen oversight of managed care organizations, validate encounter and financial data, monitor compliance, and support payment integrity. Through independent audits, data analytics, fraud, waste, and abuse identification, vendor oversight, and regulatory compliance reviews, we help agencies improve accountability, reduce program risk, and ensure the appropriate stewardship of Medicaid funding.
Strengthening Oversight, Accountability, & Payment Integrity in Medicaid Managed Care
Medicaid managed care programs require a distinct approach to program integrity. Unlike fee-for-service environments where agencies directly process and review claims, managed care shifts responsibility for service delivery, claims adjudication, and payment to contracted health plans. This model introduces new complexities related to data visibility, financial oversight, and accountability.
As managed care continues to expand across Medicaid programs, agencies must ensure payments are accurate, services are appropriate, and program requirements are met, all while maintaining effective oversight of managed care organizations (MCOs) and their subcontractors.
We support state Medicaid agencies in strengthening program integrity within managed care environments. Our work provides independent, objective analysis to enhance transparency, validate data, and support effective oversight of managed care programs.
The Shift from Fee-for-Service to Managed Care
Program integrity in managed care operates differently than in traditional fee-for-service systems. Oversight is no longer centered on direct claims review by the state, but instead relies on:
This shift requires agencies to adopt new tools, data strategies, and oversight approaches to maintain accountability across the program.
Key Program Integrity Challenges in Managed Care
Managed care introduces a range of program integrity challenges that require targeted oversight and specialized expertise.
These challenges include:
Our Approach to Managed Care Program Integrity
We take an integrated approach to managed care program integrity, combining financial, analytical, and operational expertise to support agencies in overseeing complex delivery systems.
Our approach focuses on:
Core Program Integrity Capabilities
Accurate encounter data is foundational to managed care oversight. We validate and analyze encounter data to ensure completeness, accuracy, and reliability for rate setting, reporting, and program monitoring.
We conduct audits and reviews to evaluate MCO compliance with contractual and regulatory requirements, including administrative processes, internal controls, and performance expectations.
We assess financial data submitted by health plans to support rate setting, monitor expenditures, and identify discrepancies or risks related to managed care payments.
We evaluate provider networks and access to care using quantitative analysis and tools such as secret shopper surveys to assess appointment availability and compliance with federal requirements.
We assist agencies in monitoring delegated entities, including pharmacy benefit managers (PBMs), third-party administrators, and other subcontractors, ensuring compliance and accountability across the delivery system.
We support oversight of directed payment arrangements, including validation of payment methodologies, monitoring of performance, and alignment with federal requirements.
Integration with Broader Program Integrity Efforts
Managed care program integrity is closely connected to broader program integrity activities across Medicaid programs. Effective oversight requires coordination across fee-for-service, managed care, and reimbursement systems.
We support agencies in:
Why Agencies Hire Myers & Stauffer
Our work is grounded in extensive experience supporting state Medicaid agencies in both managed care and program integrity functions. We bring:
We tailor our approach to each state’s managed care program structure, regulatory environment, and oversight priorities.
Our managed care program integrity services support:
Connect With Our Team
Partner with experts who understand the complexities of health and human services programs. Let us guide your organization through the industry’s unique challenges and opportunities.
Ryan Farrell, CFE
Principal
Email: rfarrell@mslc.com
Phone Number: 512-342-0800
Jenna Hall, CPA, CFE
Member
Email: jhall@mslc.com
Phone Number: 919-829-7430
In the Words of our Clients…
Insights on Managed Care Program Integrity
We have developed extensive thought leadership on program integrity in managed care, reflecting our experience supporting agencies across the country.
