Alivia Expertise for Government Program Integrity

Government

State and federal agencies, including government health plans, face persistent challenges, from measuring and managing healthcare quality and payment integrity to preventing losses from fraud, waste, and abuse (FWA) and overpayments, meeting regulatory demands, and addressing data security and fragmented systems.

Alivia Analytics empowers programs like Medicaid, Medicare, Medicare Advantage, State Employee Benefit Plans, and Medicaid Managed Care with trusted analytics and proven integrity solutions.

Our Expertise

We have deep expertise across multiple agencies, including State Medicaid Agencies, Centers for Medicare & Medicaid Services (CMS), the Veterans Health Administration (VHA), the Defense Health Agency (DHA), and the Centers for Disease Control and Prevention (CDC).

Alivia’s Products & Services Support:

  • Early FWA Detection that stops high-risk providers at the source with Pre-Pay Preventive Analytics and configurable rules.
  • Post-Pay Recovery Analytics that surfaces hidden leads, accelerates SIU investigations, and manages case workflows—supported by Clinical Audits and Data Mining to validate medical necessity, policy compliance, and uncover overlooked savings. Outsourced SIU is available when you have limited resources.
  • Powered by the Alivia 360™ platform that targets the “Gray Zone” between error, fraud, waste, and abuse, uncovering hidden recoveries that rules-based systems miss.
  • Recovery Audit Contractor (RAC) programs with expansions into the southeast region supporting state Medicaid RAC programs.
  • Collaboration of data-sharing analytics for bordering Region 8 populations in Colorado, Utah, and Wyoming. Utilizing both pre- and post-payment analytics, we have the resources to support your Payment Integrity programs.
  • Enhance operational performance with advanced Data & IT Transformation services that streamline data integration, modernize legacy systems, optimize claims platforms, and safeguard PHI across environments.

Compliance & Security

Built for customer confidence, Alivia ensures data protection and privacy with HITRUST r2, SOC 2 Type 2, HIPAA, and NIST CSF compliance. Our Alivia 360™ platform, products, and websites meet rigorous security standards, safeguarding sensitive healthcare data while delivering secure, reliable, and compliant solutions for government agencies and health plans.

Industry Associations

Alivia’s experts collaborate with leading industry associations, contributing to healthcare payment accuracy discussions and sharing case studies, trends, and innovations. This includes the National Association for Medicaid Program Integrity (NAMPI), the National Health Care Anti-Fraud Association (NHCAA), the California Association of Health Plans (CAHP), and others.

Frequently Asked Questions (FAQ)

Program integrity refers to the proper administration and functioning of government healthcare programs like Medicaid, Medicare, and State Employee Benefit Plans. It’s crucial for ensuring that taxpayer dollars are used efficiently, that services are medically necessary and appropriate, and that programs are protected from fraud, waste, and abuse (FWA). Effective program integrity safeguards financial resources, maintains public trust, and ensures quality care for beneficiaries.

Alivia Analytics employs a multi-faceted approach to combat FWA. Our solutions include:

  • Pre-Pay Preventive Analytics: Stopping high-risk providers and fraudulent claims before payments are made, using configurable rules and advanced algorithms.
  • Post-Pay Recovery Analytics: Identifying hidden leads, accelerating Special Investigative Unit (SIU) investigations, and managing case workflows to recover improperly paid funds.
  • Clinical Audits and Data Mining: Validating medical necessity and policy compliance, and uncovering overlooked savings opportunities.
  • Alivia 360™ Platform: Powered by advanced AI and machine learning, this platform targets the “Gray Zone” where errors, waste, and subtle fraud schemes often reside, finding recoveries that traditional rule-based systems miss.

Yes, Alivia Analytics has extensive experience supporting Recovery Audit Contractor (RAC) programs, including expansions into the southeast region for state Medicaid RAC programs. We leverage both pre-payment and post-payment analytics to identify and recover improper payments, ensuring robust support for your Payment Integrity programs.

Alivia’s SIU teams utilize advanced analytics and specialized expertise to identify patterns and trends that might indicate fraudulent activities. This enhances the speed and accuracy of investigations, leading to more effective detection and prevention of FWA.

We understand the critical importance of data protection and privacy. Alivia Analytics is built for customer confidence, ensuring compliance with rigorous security standards including HITRUST r2, SOC 2 Type 2, HIPAA, and NIST CSF. Our Alivia 360™ platform, products, and websites meet these standards, safeguarding sensitive healthcare data (PHI) while delivering secure, reliable, and compliant solutions for government agencies and health plans.

Data and IT transformation are fundamental to modern program integrity. Alivia Analytics provides advanced Data & IT Transformation services that streamline data integration, modernize legacy systems, optimize claims platforms, and improve data quality. This enhances operational performance, provides deeper analytical insights, and allows agencies to more effectively detect and prevent FWA.

Our experts actively collaborate with leading industry associations to stay at the forefront of healthcare payment accuracy and share best practices. This includes participation in organizations like the National Association for Medicaid Program Integrity (NAMPI), the National Health Care Anti-Fraud Association (NHCAA), the California Association of Health Plans (CAHP), and others. This engagement allows us to contribute to industry discussions, share case studies, and integrate the latest trends and innovations into our solutions.

The “Gray Zone” refers to the complex area where improper payments might not be clear-cut fraud, but rather a combination of errors, waste, or abusive practices that are difficult to identify with traditional rule-based systems. The Alivia 360™ platform, powered by advanced analytics, machine learning, and AI, is specifically designed to uncover these hidden recoveries by analyzing vast datasets for subtle patterns and anomalies that indicate potential FWA in this ambiguous zone.

“Alivia Analytics” and “Alivia 360” are trademarks of Alivia Analytics, LLC. All other trademarks, service marks, logos, and brand names referenced herein are the exclusive property of Alivia Analytics, LLC, unless otherwise stated.