Healthcare Program Integrity & Benefit Payment Validations


Program Integrity is a process used by the Centers for Medicare and Medicaid Services (CMS) to prevent fraud and abuse in the Medicare and Medicaid programs through ongoing detection and investigation of fraudulent or abusive billing practices among healthcare providers. Similar healthcare program integrity processes are followed by other public and private health insurance entities including other Federal agency healthcare programs, state government Medicaid programs and commercial health insurance companies. The common goal amongst all these health insurance payers is to assure payments made in behalf of their enrollees are for services that were rendered as billed, and were medically reasonable and necessary for the treatment of the patient’s illness or injury. Through effective program integrity processes, healthcare expenditures are reduced through payment avoidance or recovery of overpayments, and the savings can be otherwise used to safeguard the health and welfare of enrollees and enhance the quality of care they receive.