Medicaid Compliance Audit Services

Partner with IPRO to identify Medicaid abusers, eliminate waste and encourage provider compliance.

Detecting and deterring fraud and abuse is a central issue in Medicaid program administration. States are responsible to protect the integrity of the program and prevent taxpayer dollars from ending up in the pockets of unscrupulous providers who believe that Medicaid crime pays. The compliance audit is an important weapon in every state’s arsenal for fighting Medicaid abuse and waste.

The IPRO Solution

IPRO’s Medicaid Compliance Audit Services assist states in targeting and investigating questionable provider activity, allowing them to seek recovery of illegitimate claims. IPRO has the skilled and experienced management and technical resources needed to establish effective provider compliance auditing programs and to conduct successful audits that lead to early recovery of Medicaid funds. Our experts include claims analysts and auditors, physician and nurse reviewers, investigative and legal staff, and Medicaid and management consultants with both the knowledge and know-how to determine provider compliance with Medicaid program statutes.

IPRO’s approach to provider compliance auditing is based on the belief that sound, intelligent identification of targets conserves time and money while discouraging program abuse. Hence, our audits place a high priority on intelligence gathering, data analysis and protocol development. Our staff works closely with state and county agencies to construct an effective audit strategy and individualized audit plans and to identify realistic and appropriate provider targets.

IPRO then conducts all required pre-audit planning and audit activities, focusing on:

  • Assigning the right staff with the right skills to determine program compliance relative to billing, payment and medical necessity
  • Ensuring auditor compliance with protocols
  • Documenting all meetings and findings
  • Maintaining all work papers
  • Communicating with the governmental agency frequently
  • Issuing effective, concise and timely audit reports
  • Providing post-audit support for administrative hearings and litigation

IPRO’s services go beyond the audit itself. For example, IPRO can assist in training client staff and developing procedures and manuals for the use of their audit staff.

The IPRO Advantage

  • Over 25 years of experience collaborating with state government to implement Medicaid oversight
  • The know-how of a company that conducts over 120,000 Medicaid utilization and medical necessity reviews annually
  • The expertise of audit staff who have managed and/or executed hundreds of Medicaid billing and rate audits and are experts at identifying aberrant activity
  • The capabilities of qualified and trained registered nurses with extensive experience conducting utilization and medical necessity review
  • Hands-on expertise analyzing and handling Medicaid claims data and working with data mining analysis tools and software
  • Virtually unlimited access to physician and non-physician reviewers in virtually all specialties and subspecialties to review medical necessity and appropriateness determinations and provide expert testimony

Contact Patti Weinberg, RPA, MPS, Vice President, Medicaid/State Health Care Assessment, at 516-209-5617 or PWeinberg@ipro.org