Program Integrity
Smarter Medicaid Audits. Stronger Outcomes.
Alliant Health Solutions partners with state Medicaid agencies to identify improper payments, ensure compliance, and prevent repeat losses through clinically led, policy‑aligned audits and reviews that maintain rigor while reducing unnecessary administrative burden.
What State Medicaid Agencies Gain
- Improper payment identification with clear, policy‑based rationale and documentation.
- Recovery-ready findings with financial quantification that supports recoupment and follow‑through.
- End to end support of the review lifecycle, including provider outreach and communication, licensure and registry checks, administrative reviews, Corrective Action Plan administration, and support for legal hearings and cases.
- Pre‑payment review to stop inappropriate payments before they occur.
- Focused studies that reveal program vulnerabilities and actionable trends.
- Compliance / Non‑Claims Reviews – including validation activities such as HCBS waiver assurances (as applicable).
- ALJ hearings support, MFCU support, provider education, and structured feedback loops to medical policy teams (as applicable).
MedGuard® — Policy‑Driven Reviews That Enable Recovery
Alliant conducts reviews in MedGuard®, our proprietary, HITRUST‑certified audit platform designed specifically to support Medicaid program integrity operations.
MedGuard® enables states to:
- Apply policy‑driven review logic to provider services.
- Document improper payments with claim‑level detail.
- Capture policy citations, medical necessity gaps, and documentation deficiencies.
- Quantify recoupable amounts and distinguish recoverable findings from education‑only issues.
- Maintain organized evidence to support recovery actions, appeals, and referrals.
- Track and manage Corrective Action Plan activities, including follow up reviews.
MedGuard® is a policy‑driven tool that also records compliance and quality concerns and links findings to policy citations tied to claims and documentation.
Audit Best Practices
These practices are designed to address common state pain points—inefficient workflows, inconsistent findings, prolonged corrective action cycles, and strained provider relationships—without sacrificing defensibility.
- Risk‑informed audit planning to focus effort where impact is highest.
- Policy‑centric, system‑driven reviews to improve consistency and provider guidance.
- Efficient documentation and data request strategies that reduce agency/provider burden.
- Clearer communication and transparency across the audit lifecycle.
- Corrective Action Plan (CAP) follow‑up and re‑reviews to drive and confirm sustained compliance improvements.
- Collaboration between program integrity and policy teams to strengthen outcomes and improve policy clarity.
Alliant Delivers Measurable Results
$22.4M in overpayments identified from 3,407 reviews of waiver providers.
85.1% reduction of quality of care concerns for one waiver program.
$1.2M savings from behavioral health pre-payment reviews in FY2024 (40% of reviewed claims.
$1,631,544 potential recoupment identified in a targeted DME/O&P monitoring initiative (FY 2022).
Identified over $18.5M in fraud, waste and abuse in behavioral health services for one Medicaid managed care customer.
Our approach balances fund recovery with long‑term program integrity improvement.
Where Alliant’s Audit Rigor Matters Most
Alliant brings deep expertise in HCBS waiver programs and behavioral health, while leveraging its Peer Review Network and in-house clinical expertise for performing reviews across all service types.
- HCBS / Waivers – audits and validations that support compliance, service delivery verification, and recovery identification for all services delivered under the program, including Home Health, Structured Family Caregivers, and Personal Support Services, Respite Care, and Residential Services.
- Behavioral Health – clinically led audits focused on documentation, medical necessity support, and compliance risks.
- Across All Service Types – broad review coverage across Medicaid services and provider categories for targeted reviews which include Physician, Mid-Level Providers, Hospice, Genetic Testing, and Nursing Facilities.
End‑to‑End Audit Lifecycle Best Practices
Built to modernize audit operations while improving outcomes and reducing friction for agency staff and providers.
Design for Impact (Risk Informed Planning)
Target audits to known pain points and high‑risk areas using risk‑informed planning.
Execute with Consistency (Policy‑Centric, System‑Driven Review)
Use policy‑centric methods and system‑driven documentation to reduce inconsistency and strengthen defensibility.
Reduce Administrative Burden (Efficient Data Requests + Communications)
Use efficient documentation strategies and clearer letters/communications to reduce provider abrasion and internal friction.
Close the Loop (CAP Follow‑Up + Re‑Reviews)
Use CAP processing, follow‑up, and re‑reviews to convert findings into sustained and quantifiable compliance improvements and adherence.
Program Monitoring Experts
Alliant’s clinically-led, technology-driven process delivers consistent, actionable results, complemented by exceptional customer service.
In FY 2022, Alliant launched a DME/O&P provider monitoring initiative using data from the state’s prior authorization program and member satisfaction interviews. The goal was to monitor policy and regulatory compliance and identify potential recoupments. This initiative monitored 105 providers, 3,457 members, and approximately 10,954 claim lines.
Key findings included:
Member Satisfaction: Positive feedback
Potential Recoupment: $1,631,544, with 36% of billed service units lacking supporting documentation.
Trends:
- No face-to-face clinical exam (57%)
- Unsigned Certificate of Medical Necessity (CMN)
- Incomplete CMNs lacking specific condition details
- Missing clinician orders and signatures
Based on these findings, Alliant recommended focused desktop reviews of providers to assess compliance and identify improper payments.
87% of DME and 44% of O&P CMNs lacked required elements.
Contact
Alliant Health Solutions | 400 Perimeter Center Terrace NE, Suite 250, Atlanta, GA 30346 | P 678.527.3100 inquiry@allianthealth.org | www.allianthealth.org