Program Integrity

  • Validation & Oversight Services
  • Program & Protocol Development
  • Program Vulnerability Detection
  • Appeals & Dispute Resolution
  • Medical & Claims Review
  • Evidenced-Based Medicine Peer Reviews
  • Healthcare Fraud Detection & Identification
  • Legal Support & Testimony
  • Data Analysis
  • Program & Congressional Reports
  • Article Development

Provider Resources, Inc. (PRI) understands how to collaboratively meet the industry’s need for improving program integrity, clinical quality, and patient safety initiatives while remaining actively involved in the development of policy and regulatory efforts, with an emphasis on improving education and lowering program costs. As a former billing company, PRI has over 25 years of corporate program integrity knowledge and experience focused on Medicare, Medicaid, Workers’ Compensation, and various commercial programs. PRI has contracted either as a prime or as a subcontractor with agencies such as the Centers for Medicare & Medicaid Services (CMS), the Health and Human Services/Office of Inspector General (HHS/OIG), the United States Postal Service/Office of Inspector General (USPS/OIG), the National Institutes of Health (NIH), the Department of Veterans Affairs (VA), the Health Resources and Services Administration (HRSA), and the Agency for Healthcare Research and Quality (AHRQ). In PRI’s Program Integrity Division, the breadth of contracts demonstrates our knowledge of the coverage, manual composition, and utilization and reimbursement policies of the Medicare, Medicaid, and CHIP programs, along with associated payors such as Workers’ Compensation.

PRI’s program integrity experts are able to identify, recommend reduction strategies, and eliminate clinical and financial fraud, waste, and abuse with the ultimate goal of instilling integrity into the healthcare system at all levels. PRI comprises program integrity healthcare experts with a varied range of specialties, such as evidence-based medicine (EBM) practices, medical review, Medicare and Medicaid programs, healthcare claims pricing and validation, appeals and dispute processes, healthcare policy, medical review article development, Congressional reporting, quality improvement, patient safety, program safeguard, compliance and integrity, investigations, legal review, and data analysis.

Additionally, PRI’s program integrity experts have been selected for their high-level expertise and capability of providing education to diverse groups within high-profile, national-scope program integrity initiatives. PRI’s program integrity subject matter experts (SMEs) have designed and developed innovative solutions in order to address diverse audiences, technological challenges, and changing legislative requirements. These sessions have included beginner through advanced skill levels in both small and large group settings. Materials have included article development, environmental assessment, webinars, and in-person trainings where PRI also provided all logistical support through our Education & Outreach Division personnel. Topics have included:

  • Medical Review of Medicare Skilled Nursing Facility Services
  • Environmental Scan of 2010-2011 Enacted Legislation for its Impact on Medical Review Processes
  • Medicare Reimbursement for Drugs & Biological Products: Medical Review Considerations in Review of Drug Claims
  • DRG Validation
  • Complex DRG Validation with High Risk for Improper Payment
  • Medical Review Strategy
  • Data Analysis in Medical Review
  • Developing a Problem List
  • Inpatient One-Day Stays