Assess Program Integrity Risk Before Federal Scrutiny Exposes Gaps
Medicaid program integrity and fraud, waste, and abuse (FWA) consulting helps state Medicaid agencies, healthcare providers, and Medicaid health plans identify and mitigate risk, prevent improper payments, strengthen compliance, and prepare for federal and state audits. HMA evaluates governance, policies, data and systems, controls, organizational structures, Special Investigations Unit (SIU) and program integrity operations, provider and beneficiary oversight, documentation, and payment integrity processes to identify risk and prioritize action. The result is a defensible, measurable strategy for reducing audit exposure, improving operational performance, and protecting public healthcare dollars while aligning with the Centers for Medicare & Medicaid Services (CMS) and HHS OIG expectations.
Why Medicaid Program Integrity Matters
Medicaid program integrity becomes harder to defend when compliance, SIU/program integrity, payment integrity, analytics, provider and beneficiary oversight, and finance operate in disconnected workflows. As CMS, HHS OIG, state Medicaid agencies, and managed care contracts raise expectations, organizations need integrated governance, real-time analytics, and clear accountability to detect risk early, quantify exposure, and prevent avoidable financial loss.
| Three Shifts Happening Now | ||
| Compliance → Enterprise Accountability | Retrospective → Real-Time Risk Management | Program Protection → Enterprise Performance |
| Problem: Silos hide risk, duplicate efforts, and create inconsistent decisions. Solution: Integrated governance across program integrity, finance, operations, compliance, and analytics. | Problem: Post-payment detection allows problems to persist for months. Solution: Predictive analytics and pre-payment controls identify issues early. | Problem: Program integrity is viewed as a cost center, not a strategic asset. Solution: Alignment with business goals enables growth and risk management. |
How HMA Helps Organizations Strengthen Program Integrity
HMA views program integrity as an integrated capability—not simply a collection of separate functions. Our approach moves organizations through four interconnected phases, leveraging unique experts and expertise in each phase:
Strategic Assessment
HMA evaluates governance, organizational structure, compliance controls, SIU operations, provider screening, payment and program integrity workflows, audit history, data readiness, and alignment with federal and state expectations.
Outcome: A factual baseline of your current state, quantified financial exposure, an assessment of audit readiness, identified gaps, and strategic roadmaps
Data and Analysis
Recommendations are informed by claims, encounter data, provider enrollment files, investigation records, audit findings, documentation reviews, financial exposure analysis, and operational performance indicators.
Outcome: A strategy grounded in federal priorities and your operational realities, with clear accountability and measurable milestones
Implementation Support
HMA helps clients move from strategy to action through prioritized roadmaps, governance redesign, policy development, process/workflow improvement, staff training, analytics enhancement, and corrective action planning.
Outcome: Operationalized improvements across governance, workflows, systems, and analytics that minimize disruption while accelerating readiness
Measurement and Outcomes
Success is measured through reduced audit exposure, improved improper payment identification and recovery, cost savings and cost avoidance, stronger documentation defensibility, faster issue detection, improved SIU/program integrity unit performance, and sustained compliance monitoring.
Outcome: Embedded capabilities and dashboards that track progress, surface emerging risks, and enable continuous optimization
Why Trust HMA
HMA helps organizations translate program integrity findings into practical action. Engagements may include current-state assessments and gap analysis, financial exposure analysis, audit readiness scorecards, governance and operating model recommendations, data and capability maturity assessments, prioritized roadmaps, and executive briefings.
Where available, service pages should include client outcomes such as improper payment recovery, cost savings and avoidance, audit finding reductions, time saved through workflow redesign, improved provider screening rates, enhanced SIU and program integrity case prioritization, or quantified financial exposure identified.
Dual Expertise (Government + Managed Care + FWA)
- Former state Medicaid directors + health plan leaders + program integrity leaders = government perspective that works operationally
Federal Alignment (Not just compliance box-checking)
- We monitor CMS enforcement priorities, HHS OIG and Department of Justice patterns, and state actions and position you ahead of scrutiny
Enterprise Integration (Not siloed functions)
- Connect compliance, SIU, program integrity, payment integrity, analytics, provider and beneficiary management into coordinated system
- Earlier risk detection + consistent decision-making + reduced duplicate effort
Practical Implementation (Not experimental)
- Phased approach balances speed with sustainability
- Quick wins build momentum; change management ensures adoption
Measurable Outcomes
- Financial protection: Reduced audit exposure + accelerated improper payment recovery + cost savings and avoidance
- Compliance: Strengthened governance + federal audit readiness
- Operational improvements: Improved efficiency + enhanced FWA detection
Federal Priorities We Align With
CMS is actively scrutinizing these service lines:
- Non-Emergency Medical Transportation (NEMT): Medical necessity, provider billing, member access validation
- HCBS: EVV data, authorization alignment, documentation, service delivery
- DME: Medical necessity, prior authorization, rental vs. purchase decisions
- Behavioral Health: Treatment planning, service intensity, documentation, provider credentials
- Laboratory: Ordering patterns, medical necessity, code accuracy
- High-Dollar Claims: Outlier validation against records and authorization
- Pharmacy: National Drug Code accuracy, formulary compliance, utilization patterns
We assess your controls against these priorities to ensure audit readiness.
What You Get From An Assessment
Integrated Program Integrity Framework
Our assessment evaluates and strengthens your organization across the three core pillars of Medicaid program integrity: Prevention, Detection, and Recovery. We begin by establishing robust pre-payment controls, real-time analytics, and rigorous provider screening to mitigate risk and stop improper payments before they occur. To monitor ongoing exposure, we deploy advanced claims analysis, risk scoring, and outlier detection that identify emerging fraud, waste, and abuse in real time. Finally, we bolster your remediation capabilities by streamlining SIU investigations, medical necessity audits, and compliance resolution to ensure swift recovery of improper payments and long-term audit defensibility.
- Current-State Assessment Report (governance, compliance, SIU, program integrity, payment integrity, analytics evaluation)
- Financial Exposure Analysis (quantified improper payments + undetected fraud)
- Audit Readiness Scorecard (specific findings + recommendations)
- Governance & Operating Model Assessment (evaluating organizational structure, data readiness, and analytics capabilities).
- Prioritized Roadmap (phased strategy with milestones + resource requirements)
- Executive Briefing (board-ready presentation materials)
Frequently Asked Questions
How long does an assessment take?
An assessment takes 6–12 weeks, depending on scope. We balance rigor with operational impact.
What does it cost?
Cost varies by scope. Assessments typically surface enough opportunity to fund roadmap development and implementation.
We just had a state audit. Can you help?
Yes. We help develop credible corrective action plans and use findings to inform broader strategy—not just react to this audit.
We have legacy systems. Can you work with what we have?
Yes. We assess where you are and recommend whether to upgrade technology, improve processes, or both. We don’t sell technology; we solve problems.
How do we balance compliance cost with ROI?
Program integrity investment should pay for itself. High-ROI activities: delegated entity oversight, data quality improvement, RADV prep, targeted analytics.
One of the 13 states under scrutiny is our competitor. What does that mean?
It means federal expectations are clarifying in real time. States that assess vulnerabilities proactively are better positioned than those that react after federal action begins.
Connect with an HMA program integrity expert to assess risk, understand federal and state expectations, and identify the actions that can strengthen your program integrity posture.ort.
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