Program integrity is moving from the back office to the boardroom

Program integrity is moving from the back office to the boardroom.

The latest enforcement activity should have every healthcare payer asking a bigger question: Are we identifying risk early enough — or explaining it after the fact?

HHS-OIG recently reported billions of dollars in monetary impact from its fraud, waste and abuse efforts, while federal agencies continue to increase scrutiny of Medicaid, Medicare Advantage and other federally funded healthcare programs.

The shift is significant.

Program integrity can no longer operate only as a reactive function focused on recovering dollars after questionable claims have already been paid.

The strongest programs connect: Data → Intelligence → Investigation → Action

Analytics can identify what looks different.

Experienced investigators determine why.

For health plans, the question is increasingly becoming not simply:

“Can we find anomalies?”

But:

“Can we defend what we did once we found them?”

Source: https://lnkd.in/eE66BkUQ