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Program Integrity

  • Health care fraud detection
  • Predictive Analytics
  • Data Analysis
  • Claims Review
  • Financial Audit
  • Compliance Program Development and Reviews
  • Fraud and Abuse Training

Scenario

Improving Program Integrity and Contractor Management

Client Challenge:

A division of the Centers for Medicare & Medicaid Services (CMS) was responsible for the administration of a fraud, waste and abuse program to safeguard public funds of $163 billion. The responsibility for program administration rested with CMS while execution was delegated to a contractor who conducted data analysis, fraud investigations, audits and complaint processing. CMS recognized that the program was relatively new and hurriedly implemented in response to new legislation and desired to improve overall program management and enhance fraud detection outcomes.

The Rainmakers Solution:

Rainmakers provided subject matter experts in the areas of health care and fraud investigations who assisted CMS with the identification of key objectives and strategic planning. In addition, we conducted a thorough analysis of CMS management practices and contractor activities. Based on our findings and the gaps identified, we developed a series of strategies and tools to assist CMS to improve program management. Specific solutions included: a risk-based, goal-oriented performance management and evaluation plan, a reporting system that provides ongoing transparency into contractor activities and achievements, a set of audit tools to be used by the contractor to identify, prioritize and address program vulnerabilities, a data management and analysis plan, tools for determining return on investment, communication strategies for internal and external stakeholders, and recommendations for future contractor acquisitions.

The Result:

CMS now has the tools and management processes to more effectively manage their contractor, safeguard program funds and protect beneficiaries. In addition, CMS is better prepared to respond to inquiries and investigations from external agencies such as Office of Inspector General, General Accounting Office and Congress.

Program Integrity

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The Rainmakers Solutions