A focused review of whether the organization can substantiate the Medicaid services for which it receives reimbursement. 

• Provider enrollment and revalidation information 

• Ownership, managing-employee, credential, and screening records 

• Member eligibility and service authorization 

• Service necessity and covered-service requirements 

• Documentation supporting service delivery 

• Staff qualifications and service eligibility 

• Codes, modifiers, units, dates, and time 

• EVV or other time-verification records when applicable 

• Duplicate, overlapping, or inconsistent service patterns 

• Billing controls, overpayment identification, and refund processes 

• Internal auditing and program-integrity oversight 

Core review pathway: Authorization → Service Delivery → Documentation → Claim → Payment. 

A targeted sampling engagement that traces paid Medicaid claims backward through the evidence required to substantiate them. 

• Member and provider eligibility 

• Service authorization 

• Service date and type 

• Service documentation 

• Qualified staff 

• Time and units 

• Code/modifier accuracy 

• EVV, payroll, schedule, or other corroborating evidence when applicable 

• Payment and adjustment history 

Sample classifications may include Substantiated, Documentation Deficiency, Needs Follow-Up, or Potentially Unsupported. A red flag triggers additional review; it is not a fraud determination. 

A targeted readiness assessment for providers operating within Minnesota Medicaid service categories subject to heightened program-integrity oversight. 

• Enrollment and revalidation accuracy 

• Ownership and managing-employee information 

• Required screening and background studies 

• Credential and insurance documentation 

• Physical-site readiness 

• Personnel and training records 

• Service documentation 

• Claim substantiation 

• Internal billing controls 

• Response readiness for document requests or site review 

Scope is customized to the specific Medicaid service and current MHCP requirements.m description

Focused support when a provider has already identified a serious compliance problem or received an external finding. 

• Licensing or regulatory findings 

• Corrective-action requirements 

• Medicaid documentation or billing deficiencies 

• Revalidation or site-visit concerns 

• Payer or government document requests 

• Audit findings 

• Potential overpayments 

• Policy, training, or operational deficiencies 

Method: Triage → Root Cause → Corrective Action → Implementation → Validation. 

Ongoing compliance infrastructure for organizations that need executive-level support without a full-time quality/compliance executive. 

• Internal compliance audits 

• Regulatory monitoring 

• Quality and program-integrity dashboards 

• Incident and complaint trending 

• Corrective-action monitoring 

• Policy oversight 

• Billing/documentation sampling 

• Quality or compliance committee facilitation 

• Leadership consultation 

• Staff and supervisor education 

• Annual compliance and quality planning 

Engagements can be structured as recurring monthly support based on organizational size, service mix, and risk.