National overview · MedIntegrity OS

Prepayment review operations

CMS FY2024: $31.1B improper payments (5.09% rate). 84.3M beneficiaries · $931.7B expenditure. Modeled prevention targets.

81.8K

6-month cohort · T-MSIS volume benchmark

$169,217

Flagged anomalies pending analyst disposition

Pilot-readiness scenario · No live MMIS integration

47/hr

Modeled adjudication throughput

Demonstration environment · synthetic data · no PHI

$450 flagged exposure per analyst hour (modeled) 847 signals in queue

QUEUE: EAST-CORRIDOR-17 · ANLST: TWASHINGTON

Illustrative National Impact Scenario

CMS FY2024 savings estimate. Modeled.

Illustrative national impact scenario indicators and values
Indicator	Value
Modeled scenario estimate Modeled from CMS FY2024 rate applied to national Medicaid expenditure	$1.6B–$2.4B
Potentially adaptable state Medicaid programs State Medicaid programs under CMS oversight (42 CFR Part 430)	50
1.2B claims modeled at national scale Annual evaluation capacity benchmarked to CMS T-MSIS volume. Modeled.	1.2B
Modeled routing performance target Modeled target. Not a validated performance measure.	94.3% Modeled target. Not a validated performance measure.

Modeled scenario estimate

Value: $1.6B–$2.4B
Basis: Modeled from CMS FY2024 rate applied to national Medicaid expenditure

Potentially adaptable state Medicaid programs

Value: 50
Basis: State Medicaid programs under CMS oversight (42 CFR Part 430)

1.2B claims modeled at national scale

Value: 1.2B
Basis: Annual evaluation capacity benchmarked to CMS T-MSIS volume. Modeled.

Modeled routing performance target

Value: 94.3%
Note: Modeled target. Not a validated performance measure.
Basis: Modeled target. Not a validated performance measure.

Operational Analytics

Claims evaluation volume, national cohort.

Claims evaluated by month

National cohort. Source basis: CMS T-MSIS FY2024 reporting parameters

Methodology

Claims volume modeled on CMS T-MSIS national Medicaid reporting parameters

Framework Impact Summary

ROI indicators for policy review.

$1,410/ FTE-month

Modeled prevented exposure per analyst load

68% earlier intervention

Modeled shift to prepayment review

99.2%

Synthetic benchmark. Not a certified outcome measure.

Regulatory Alignment

Federal program integrity authorities.

CMS Center for Program Integrity

Designed with reference to publicly documented Medicaid program integrity priorities. Prepayment review, audit trails, and program integrity reporting concepts. No CMS, OIG, MFCU, or state agency endorsement implied.

Technical Reference Framework Documentation

Designed with reference to OIG Medicaid oversight priorities

Methodologies mapped to federal Medicaid program integrity priorities and oversight focus areas. No CMS, OIG, MFCU, or state agency endorsement implied.

Technical Reference

Designed to align with 42 CFR Part 455 program integrity concepts

Federal Medicaid provider screening and claims integrity regulatory structure.

Audit trail Framework Documentation

HIPAA Data Handling Standards

Role-based access, encryption, minimum-necessary data for PHI-adjacent operations.

Framework Documentation

Program integrity reporting concept

Structured for state MIP-style reporting, corrective-action tracking, and federal reconciliation concepts. No CMS, OIG, MFCU, or state agency endorsement implied.

Technical Reference

MFCU referral package preparation concept

Referral pathways and case packages structured for MFCU coordination and program integrity review handoff. No CMS, OIG, MFCU, or state agency endorsement implied.

Audit trail Technical Reference

Performance Indicators

Operational metrics, national deployment.

81.8K

National cohort · CMS T-MSIS FY2024 basis

847

Modeled alerts in analyst review queue

$169,217

Prepayment anomalies flagged (modeled)

2.4 hrs

Detection to analyst desk. Modeled SLA benchmark.

Deployment Readiness Modeling

Jurisdiction readiness · MedIntegrity OS

State readiness grid

Deployment modeling scenarios

Modeled

Pilot-readiness

Configured

Pending

Readiness legend

Modeled: Fully configured demonstration scenario
Pilot-readiness: Pilot-readiness model: illustrative scenario for limited-scope supervised review
Configured: Framework configured. Pending analyst onboarding.
Pending: Available for deployment. No MMIS connection in this environment.

Illustrative deployment readiness scenarios. No live state MMIS connections.

Signal Feed

Risk stratified queue. Disposition required.

Last updated: Jul 7, 2026, 04:39 AM UTC

Analyst signal queue with risk scores, regulatory basis, and disposition
Timestamp	Case ID	Provider	Flag Type	Regulatory Basis	Est. Exposure	Assigned Analyst	Disposition	Audit Trail
Last updated 2 min ago · Auto-refresh paused
May 18, 2026, 02:22 PM	MIO-2026-04182	Riverside Community Health	Billing Velocity Anomaly	42 CFR 455.23	$3.2M	Unassigned	Pending	0 prior
May 18, 2026, 11:05 AM	MIO-2026-04171	Lakewood Pharmacy Services	Provider Network Concentration	CMS-2390-F	$912K	K. Lopez	In Review	2 prior
May 17, 2026, 04:48 PM	MIO-2026-04158	Central Valley Transport Network	Transportation Route Anomaly	42 CFR 455.23	$287K	M. Torres	Escalated	1 prior
May 17, 2026, 09:30 AM	MIO-2026-04144	Oakdale Medical Supply	Cross-County Referral Pattern	Federal Medicaid program integrity priorities	$176K	D. Park	In Review	3 prior
May 16, 2026, 01:15 PM	MIO-2026-04129	Greenfield Care Associates	Upcoding Frequency	CMS-2390-F	$108K	M. Torres	Pending	1 prior
May 16, 2026, 08:02 AM	MIO-2026-04112	Westbrook Behavioral Health	Utilization Outlier	42 CFR 455.23	$73K	Unassigned	Pending	0 prior