Compliance Programs
Nearly every day, we hear in the news that one of our government programs was bilked out of millions of dollars. The targeted agency most likely believed its compliance program was “air tight.” However, testing was never performed to make sure.
A credible reimbursement program mandates a parallel compliance program to ensure payments for services are accurate, timely, and only for services actually rendered.
IntegriGuard offers its audit experience to test internal controls and processes with the goal of identifying gaps in compliance programs. Our established processes monitor compliance programs, educate staff regarding compliance requirements, and research regulatory changes that impact compliance programs.
Agency or company money can disappear fast. Unfortunately, it is all too common for agencies not to know how it is leaving or where it is going.
We believe in using proactive analysis to identify improper payments for our clients. Using technology-driven auditing solutions, our data analysts identify areas of vulnerability and provide focused investigative targets. In addition to our trending and analysis capability, we analyze data to monitor the billing behavior of individuals and companies that are or have been under investigation.
Our investigative reviews for our clients have, at times, found nothing more than billing errors requiring education of staff. At other times, our investigation has established much more. We have uncovered the diversion of hundreds of thousands of dollars from the care of the elderly, and we have discovered shells where businesses should have been operating.
Our healthcare fraud team investigates identified leads using a variety of tools and techniques. When an investigation yields evidence indicative of fraud, we develop the case file, provide detailed claims analysis, work with appropriate law enforcement agencies for acceptance, and continue to provide support through sentencing and conviction.
Page by page: Medical documentation contains a lot of information. Word by word: Our medical documentation reviewers expertly recognize any aberrancies and incongruities for our clients.
Our licensed clinicians are solidly grounded in knowledge of the benefit program. These professionals use that knowledge to assess if services were rendered and/or medically necessary and if quality of care concerns existed. Each record review articulates findings as well as cites the law, regulation, or coverage policy that supports the determination. Our rigorous quality monitoring program measures the accuracy and consistency of each review.
Providing benefits for the wrong people can be costly to any agency. Sorting out the errors can take too much time. Knowing how to do both takes experience.
IntegriGuard has devised innovative ways to receive, process, and report eligibility, enrollment, and payment accuracy work. We collaborate with key stakeholders to develop uniform submission process. Our databases quickly identify duplicate and erroneous requests minimizing processing and reporting time.
Cost reports….compliance…prepayment audits....targeted reviews….onsite, desktop, unannounced site visits…proactive auditing. Depending on what is needed, our experienced audit team has the tools required to get the job done.
Each IntegriGuard audit is tailored to a specific investigation. Our auditors and accountants have a wide range of audit experience, which includes auditing drug card plans, managed care organizations, and healthcare facilities. We strive to achieve 2007 Government Auditing Standards to ensure each audit plan tests the agreed upon controls, is well supported by documentation, and is reviewed appropriately at each step. Our auditors look at a variety of items, including claims, financial statements, general ledgers, cash disbursements, journals, and adjusting trial balances.
