Audit Medicaid Integrity Contractor (MIC)

As the Audit MIC for three Task Orders (in 34 states and DC /6 of 10 CMS Medicaid regions), Qlarant evaluated and subsequently audited potential fraud, waste, and abuse of Medicaid claim dollars by beneficiaries and all types of providers. Using investigators, nurses, CPAs and auditors, Qlarant worked closely with the states in its jurisdictions to examine Medicaid health claims and/or identify issues of medical necessity and appropriateness of care when the medical records of an individual or provider were evaluated. The MIC conducted audits of paid Medicaid claims across all provider types and settings of care to find overpayments or potential fraud. In addition, the MIC staff and subcontractors often identified Medicaid areas based on research of policies and procedures for which CMS and/or states conducted data analytics that led to audits. This experience-based assessment of the vulnerable areas produced significant audit results. Internal Qlarant and subcontractor auditors/nurses performed GAGAS audits, within budgeted hours, to identify improper payments due to program rules violations, lack of medical necessity, or delivery of inappropriate care. Comprehensive reports were submitted to CMS for review and to the state and provider overpayment collections. As warranted, referrals were made to law enforcement.