Strengthen Program Integrity Across Plans, Programs, and Delegated Entities
HMA helps Medicaid health plans assess program integrity maturity, strengthen delegated entity oversight, improve SIU operations, enhance claims and encounter data processes, and prepare for audits, RADV reviews, and evolving state and federal expectations.
Why Program Integrity Maturity Matters for Medicaid Health Plans
Plans manage program integrity across multiple programs (Medicare, Medicaid, ACA, SNPs) with different rules, different auditors, different consequences. Delegated entities add complexity. Rising audit frequency + RADV reviews + OIG investigations create growing risk.
What Medicaid Health Plans Engage HMA For
How do we integrate fragmented program integrity functions across programs and delegated entities to reduce audit exposure and improve financial performance?
Program Integrity Maturity Assessment
Evaluate delegated entity oversight, claims/encounter data, SIU operations, analytics, compliance
Delegated Entity Oversight Framework
Strengthen monitoring, performance metrics, audit readiness, corrective action
Claims & Encounter Data Management
Improve data quality, integration, analytics across all sources
SIU Workflow Optimization
Redesign for efficiency, improve case prioritization, strengthen methodology
Risk Scoring & Analytics
Develop fraud/waste/abuse/error prediction models; focus investigative resources on high-impact cases
RADV & Risk Adjustment Readiness
Prepare for CMS documentation reviews
Why Medicaid Health Plans Trust HMA
Medicaid health plans trust HMA to bring structure, clarity, and operational experience to complex program integrity challenges across plans, programs, and delegated partners.
- Manage cross-program complexity (Medicare, Medicaid, ACA, DSNP/SNP)
- Strengthen delegated entity oversight with structured monitoring
- Integrate fragmented data for better detection and decision-making
- Improve SIU effectiveness through better case selection and methodology
- Team includes SIU directors, payment integrity leaders, risk adjustment experts (we understand plan operations)
Frequently Asked Questions
How do we make sure delegated entities are complying?
Delegation doesn’t eliminate plan responsibility. CMS expects active oversight through documented agreements, regular monitoring/auditing, performance metrics, corrective action. Many plans have weak oversight of delegated SIU work–this creates audit exposure.
Talk with an HMA expert to identify exposure, clarify expectations, and prioritize high-impact next steps.
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