Medical Fraud
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Need clarity on recent CMS ruling? Preparing for an OIG audit? Want to verify state-level Medicaid policies for a case?
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Know More About The Services
Comprehensive Medicaid Research
- Eligible framework's, state–specific guidelines, and policy comparisons
- Medicaid waivers (1115, 1915(c), etc) analysis
- Managed care plans and state agency processes
- Audit findings, sanctions and corrective action trends
OIE investigations and compliance monitoring
- In depth analysis of OIG reports, enforcement actions, exclusions
- Monitoring and research of corporate integrity agreements (CIAs)
- Risk assessments related to fraud, waste, and abuse
- Advisory on best practices for compliance and self–disclosure protocols
What we offer
Our tailored services provide a deep dive into the regulations, guidelines, enforcement actions, policy changes, and compliance requirements that govern Medicaid and CMS programs. Whether you are preparing for litigation, conducting due diligence, or managing risk, we provide the intelligence and support needed to act with confidence.
CMS regulatory intelligence
We analyzed and interpret:
CMS rules making proposed–final rules, FAQs, MLN matters)
Provider enrollment and PECOS regulations
Payment policies (RBRVS, DRG, DSH, MACRA, etc.)
Cross – program impact between Medicaid and Medicare
Medicaid Fraud – Key Regulatory Bodies and Standards
These agencies and standards collectively form a layered enforcement and oversight framework to detect, deter, and prosecute Medicaid fraud across federal and state levels.
Centers for Medicare & Medicaid Services (CMS)
CMS administers the Medicaid program at the federal level. It sets policy regulatory requirements and oversight mechanisms working with state Medicaid agencies to enforce program integrity, including the Medicaid integrity Program (MIP) and data-driven fraud prevention tools.
Medicaid Fraud Control Units (MFCUs)
Operated at the state level but jointly funded by federal and state governments, MFCUs investigate and prosecute Medicaid fraud by healthcare providers as well as patient abuse and neglect in Medicaid-funded facilities. MFCUs follow federal performance standards set by the OIG to ensure effectiveness and compliance.
Office of Inspector General (OIG)
Part of the US department of health and human services (HHS), the OIG is responsible for detecting and preventing fraud, waste and abuse in HHS programs, including Medicaid. It issues compliance guidance audits and investigations and enforces civil monetary penalties for fraud – related violations.
US Department of Health and Human Services (HHS)
Oversees the administration of federal health programs like Medicaid. Through its various agencies, including the OIG and CMS, it sets broad policy funding, and oversight strategies to ensure integrity and accountability.