Blog

Great conversations. Important work ahead. Thank you to Medicaid Health Plans of America (MHPA) and the Medicaid managed care community for a great few days in San Antonio! One thing remains clear: stronger program integrity requires more than identifying risk. It...

Almost everyone in healthcare is talking about AI. That's why simply saying “we use AI” is quickly becoming less meaningful. The more important questions are: What does your AI detect? What information can your analytics connect? Can you identify emerging schemes...

Medicare Advantage risk adjustment continues to be an area worth watching. In a newly released audit, HHS-OIG found that many of the selected high-risk diagnosis codes it reviewed were not supported by the underlying medical records, resulting in a significant...

A recent DOJ case involving D.C. Medicaid offers a useful reminder about behavioral-health program integrity. A registered nurse pleaded guilty in connection with a $14 million healthcare fraud scheme involving mental-health services that were never provided or...

CMS announced on September 22 that it is canceling approximately 315,000 unauthorized Marketplace enrollments covering more than 760,000 individuals. They expect this will return roughly $2.2 billion in subsidies. CMS says its response includes coordinated data...

Payment integrity doesn’t become proactive by adding more tools. It becomes proactive when leaders can actually see what’s happening across the program. A recent Fierce Healthcare article gets at a challenge we see often: payers may have internal tools, outsourced...

Great conversations. Strong connections. Important work ahead. Thank you to the Ohio Association of Health Plans and everyone who joined us in Columbus for the 2026 OAHP Annual Convention & Trade Show! Identify. Investigate. Protect. #OAHP #OAHP2026 #HealthPlans...

Our CoventBridge Combination is Where Stronger Program Integrity Begins! #ProgramIntegrity #HealthcareAI #FraudAnalytics #SchemeDetection #Medicare #SIU #FraudInvestigations #HealthcareFraud #PaymentIntegrity #RevenueIntegrity #FWA #FraudWasteAndAbuse #Investigations...

Healthcare fraud is becoming harder to detect through isolated claims alone. CMS recently announced that its enforcement actions stopped more than $1.6 billion in potentially improper Medicare laboratory payments, including $732 million tied to the revocation of 157...

Payment integrity is moving upstream. Our thinking has to move with it. As HPRI wraps up in Chicago, one theme stands out: stronger payment integrity increasingly means identifying risk earlier, connecting the right data, and acting before issues become more costly....

AI and analytics are transforming healthcare investigations. But one question still matters: Who picks up the case after the system finds something? For some organizations, field investigation is outsourced only when a case reaches a certain threshold. That model can...

Some healthcare fraud can't be fully investigated from behind a computer. Home health is a perfect example. Federal enforcement continues to focus heavily on this sector. On August 4, DOJ announced charges against 19 defendants in Medicaid home health aide schemes,...

A provider identifier can be valid. The person using it may not be. DOJ recently announced charges in a Kentucky Medicaid case that illustrates why provider identity deserves attention as a program-integrity issue. According to the August 27 indictment, a medical...

The most expensive fraud investigation may be the one that starts after the money is already gone. Healthcare program integrity has traditionally relied heavily on a familiar model: Pay → Detect → Investigate → Recover But regulators are increasingly emphasizing...

“Our SIU has a full staff of investigators.” But what does “investigator” actually mean? In healthcare SIU work, that distinction matters. Many organizations use the term broadly — sometimes referring to analysts, researchers, or desk-based investigators who work...

Thank you NAMPI 2026 and the Medicaid program integrity community for the conversations, collaboration and shared commitment to protecting critical programs. [video width="1920" height="1080"...

Prevention is getting earlier. Detection is getting smarter. Investigation still determines what’s real. As #NAMPI2026 comes to a close in Portland, one thing is clear: Medicaid program integrity is continuing to move upstream. Prepayment review. Connected data....

Earlier detection is changing Medicaid program integrity. But detection is not the finish line. One theme coming through clearly at #NAMPI2026 is the industry's continued move upstream. -> Prepayment review -> Advanced analytics -> AI-informed detection -> Connected...

Fraud is rarely just one claim, one provider or one data point. That’s one of the reasons conversations happening this week at NAMPI 2026 matter. As Medicaid program integrity leaders come together in Portland, there’s increasing focus across the industry on finding...

When the way healthcare gets paid changes, fraud changes with it. The shift from fee-for-service toward value-based care was designed to reward better outcomes rather than simply more services. But changing financial incentives doesn't eliminate fraud, waste and...

An excellent read — and an important glimpse into how the healthcare fraud enforcement environment may continue to evolve. One takeaway stands out: health plans and healthcare organizations may increasingly need to navigate a growing volume of guidance, shifting...

Next stop: NAMPI 2026 in Portland. Our CoventBridge Integrity Systems team is looking forward to joining Medicaid program integrity leaders from across the country to exchange ideas, examine emerging fraud, waste and abuse challenges, and discuss what it takes to turn...

Your data can tell you something looks wrong. It can't always tell you why. We have access to more sophisticated analytics, AI and fraud-detection technology than ever before. That's a good thing. But an algorithm can identify: → An unusual billing pattern → A...

Healthcare fraud is no longer confined by state lines — or even U.S. borders. The 2026 National Health Care Fraud Takedown showed just how major international healthcare schemes have become. DOJ announced charges against 455 defendants involving more than $6.5 billion...

Telehealth changed where healthcare can happen. It also changed where healthcare fraud can happen. The risk isn't telehealth itself. It's the ability for bad actors to connect patients, , providers, prescriptions and claims across hundreds — or thousands — of miles...

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...

The next frontier of healthcare fraud may not look like the last. As payment models continue to evolve, value-based care is creating new opportunities to improve quality and outcomes—but it is also changing where risk can emerge, how improper activity may be...

We are proud Diamond Partners of the Michigan Association of Health Plans. Don't forgot to join us next week at the MAHP Annual Conference!

Medicaid Budget Pressures Put Program Integrity in the Spotlight. As states face growing Medicaid budget challenges, managed care organizations are under increased pressure to identify savings, reduce improper payments, and strengthen fraud, waste, and abuse...

In case you missed it, the Office of Inspector General (OIG) has released Industry Segment-Specific Compliance Program Guidance. This comprehensive guide covers several key areas: • Access to Care • Marketing and Enrollment • Risk...