CMS Progam Integrity Assessment

Averaging more than 15 years of experience in the healthcare industry, our consultants have worked in a variety of management positions within commercial and government payer organizations, so we understand your challenges first-hand —including competitive pressures, organizational obstacles, and limited resources.

Case Overview

A non-for-profit regional health plan brought in the Change Healthcare Consulting Team to complete a payment integrity (PI) assessment. Although payment integrity activities occurred within multiple departments, the plan lacked standardized metric reporting. The health plan had no overall corporate targets in place nor a consistent methodology for identification and reporting of results. The client asked the Consulting Team to complete an end-to-end evaluation of its current processes, compare and contrast its operations against industry standards, and provide recommendations on establishing metrics, expanding opportunities for additional areas of review and investigation, and ensuring overall program compliance.


The consulting team discovered a variety of opportunities for improvement in areas that were rife with inefficiencies, causing profit loss and creating additional work for team members. These challenges included:

  • Inter-departmental reporting misalignment
  • Missing high-dollar opportunities
  • Current results below industry reporting standards
  • Failure to identify pharmacy claim(s) along with other areas of opportunities

This customer struggled with lower recovery rates due to departmental disparity with its Payment Integrity Program(s). The team offered multiple recommendations and approaches to address and solve these issues.


Following an enterprise Payment Integrity assessment and problem identification tactics, the team provided various recommendations, including:

  • A list of solution partners to support its revamped Payment Integrity Program and help ensure high quality standards.
  • A roadmap to help the client realign departmental payment integrity initiatives to incentives, based upon industry best practices

The Change Healthcare Consulting team also helped the client implement new solutions to:

  • Streamline the payment integrity process
  • Provide stakeholders in multiple departments with more flexible, transparent reporting


  • New programs implemented
  • Addressed internal reporting structure to help create more appropriate alignment of the overall Corporate Payment Integrity Program
  • Streamlined reporting
  • Evaluated vendors

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