Program Integrity
Protecting program dollars. Improving healthcare outcomes. Strengthening trust
Verve delivers data-driven program integrity solutions that help federal healthcare programs identify improper payments, detect fraud, waste, and abuse, improve payment accuracy, and strengthen program compliance.
Our multidisciplinary teams combine clinical expertise, medical coding, claims analysis, data analytics, program management, and healthcare policy knowledge to transform complex healthcare data into actionable insights.
Our goals
What program integrity work is for
Reduce improper payments
Identify potential payment errors and opportunities for improved payment accuracy.
Strengthen fraud, waste and abuse detection
Surface patterns and indicators requiring additional review.
Improve medical review efficiency
Combine technology-enabled screening with expert clinical review.
Increase coding accuracy
Identify coding and documentation issues that can affect payment and program integrity.
Strengthen program controls
Identify vulnerabilities and support corrective actions.
Improve beneficiary and provider outcomes
Promote accurate payments, appropriate utilization, and greater confidence in healthcare programs.
Our capabilities
Five areas of program integrity work
Fraud, waste and abuse detection
Identify unusual billing patterns, aberrant utilization, potentially fraudulent activity, and other indicators of program vulnerabilities.
- FWA identification and referral support
- Provider and beneficiary profiling
- Outlier and anomaly analysis
- Billing pattern analysis
- Investigative support
- Lead development and case support
Medical review and claims analysis
Apply clinical and technical expertise to determine whether healthcare services are appropriately documented, coded, billed, and reimbursed.
- Medical record review
- Claims review
- Clinical validation
- Medical necessity review
- Utilization review
- Documentation assessment
- Pre-payment and post-payment review
- Provider-specific and service-specific analysis
Medical coding and payment accuracy
Improve the accuracy and integrity of healthcare claims through expert coding and documentation review.
- ICD-10-CM/PCS coding
- CPT and HCPCS coding
- Evaluation and management review
- DRG validation
- Coding accuracy audits
- Documentation and coding education
- Error identification and correction
- Payment integrity analysis
Audit and compliance
Support healthcare programs in identifying vulnerabilities and strengthening controls across the program lifecycle.
- Compliance assessments
- Program vulnerability assessments
- Payment error analysis
- Audit support
- Corrective action planning
- Policy and regulatory compliance
- Internal control assessments
- Documentation and reporting
Data analytics and technology
Turn large and complex healthcare datasets into actionable intelligence. Verve combines healthcare domain expertise with analytics and automation to identify patterns that may not be visible through traditional review methods.
- Claims data analytics
- Predictive and descriptive analytics
- Beneficiary utilization analysis
- Automated anomaly detection
- Data quality assessment
- Dashboard and reporting solutions
Integrated healthcare expertise
Program integrity requires more than analyzing claims
It requires understanding how healthcare is delivered, documented, coded, billed, and reimbursed. Verve brings together professionals with expertise across:
Clinical and medical
- Physicians
- Nurses
- Pharmacists
- Clinical reviewers
- Healthcare professionals
Coding and documentation
- Certified medical coders
- Documentation specialists
- Clinical documentation experts
Program management
- Program managers
- Quality assurance specialists
- Policy and compliance professionals
- Reporting and performance management experts
Technology specialists
- System and data architects
- Data scientists
- Data analysts
- Business requirement analysts
- Quality assurance
Why Verve
Why agencies bring program integrity work to Verve
Healthcare expertise
Our professionals understand the clinical, coding, operational, and regulatory complexities behind healthcare claims and payment decisions.
Data-driven decision making
Analytics transform large volumes of healthcare data into actionable intelligence.
Scalable review operations
Verve can support high-volume claims, medical record, coding, and analytical workloads while maintaining consistent quality standards.
Technology and human expertise
Automation and AI-enabled capabilities are combined with experienced healthcare professionals to improve efficiency without eliminating human judgment.
Quality focus
Our approach emphasizes accuracy, consistency, documentation, quality assurance, and defensible review processes.
Federal healthcare experience
Verve understands the mission, security, compliance, and operational requirements associated with supporting federal healthcare programs.
Next step