Claims Review and Program Integrity

Please click here to download a copy of Myers and Stauffer's 2009 National Association of Medicaid Program Integrity (NAMPI) Conference presentation entitled, “Detecting Fraud, Abuse, and Errors in Fee-for-Service and Managed Care”.

Myers and Stauffer assists state Medicaid agencies on claims payment analysis projects from both a fraud perspective and a payment integrity perspective. Our experience includes program integrity services such as fraud and abuse detection, utilization review, recipient lock-in, payment accuracy measurement studies, forensic auditing, litigation support, Medicaid payment and eligibility testing, cost report audit and desk review services, development of state reimbursement systems, defending reimbursement rates and audit findings from health care providers’ administrative and judicial challenges, and performing other data management and analysis services. Under contract with the Department of Justice, we assisted with several national health care fraud investigations including a high profile nursing facility cost report fraud investigation and smaller cases involving Medicaid programs.

Myers and Stauffer has assisted its clients with payment error rate measurement (PERM) projects since the beginning of the payment accuracy measurement (PAM) program in 2001. As part of the PAM and PERM pilots, Myers and Stauffer conducted eligibility reviews for five states. In addition to PERM, our experience includes serving as a payment integrity and specialized audit contractor for five Medicaid programs, as well as providing utilization management and cost containment strategies for many other state Medicaid programs. We have developed more than 300 proprietary computer algorithms designed to detect instances of inappropriate payments, including inappropriately coded claims, inappropriately processed claims, and anomalous/inappropriate utilization patterns.

Myers and Stauffer is an advocate for the programs we serve. The firm has an interest in the integrity of the program policies and accuracy of payment outcomes for our clients. In keeping with this philosophy, we take a vested interest advising clients of inconsistencies or aberrations in program policy, payment errors, or suspicious claims activity that we identify on their behalf.