Pillar 2 / Retroactive Verification / State Medicaid Fraud Control Unit (MFCU) Director
Retroactive investigation infrastructure for state MFCUs.
Your MFCU runs on a finite federal cost-share budget and a five-year provider lookback window. Retroactive Verification turns that window into reproducible per-provider investigations: claim-pattern detection, statutory-element mapping, beneficiary-ownership pierce, and court-portable CREB(TM) per case. OIG 90% federal cost-share eligible per 42 CFR 1007.20.
Five years of claims data, finite investigators, and OIG reporting expectations that demand reproducible methodology.
State MFCUs face a structural challenge: hundreds of provider referrals per year, five years of claim data to analyze per case, OIG reporting expectations requiring documented methodology, and finite investigator headcount. Retroactive Verification turns the five-year window into deterministic per-provider investigations that scale with your case volume, not your headcount.
- 42 CFR Part 455 (program integrity). State Medicaid fraud, waste, and abuse review obligations. Per-provider claim-pattern detection with statutory-element mapping to false claims, false statements, and false records.
- OIG 90% federal cost share. 42 CFR 1007.20. Retroactive Verification engagements qualify for 90% federal cost-share when used for fraud detection in approved MFCU operations.
- State FCA + AKS variant statutes. Per-state element mapping (NY, CA, TX, FL, IL Medicaid FCAs; Stark; AKS) so the referral package to your state AG is ready to file.
- Provider exclusion list management. Per-provider OIG LEIE + state exclusion list check, plus continuous monitoring for newly excluded providers in your claim window.
Provider 5-year retro screen
Per-NPI five-year lookback with claim-pattern detection, fraud-trigger ratios (high billing density, low-acuity inflation, code-set anomalies), and statutory-element mapping. Output: SHA-256-sealed per-provider report.
Beneficial-ownership pierce
Per-LLC/holding-co analysis surfacing corporate veil + UBO mapping. Critical for identifying provider straw-party recipients of Medicaid payments.
Pre-referral evidence packet
Court-ready CREB(TM) ready for state AG referral. Includes evidence index, statutory-element map, deposition prep, and expert-witness reference.
Continuous exclusion monitoring
Subscription to OIG LEIE + state exclusion list updates. Per-provider attestation on continued eligibility. Alerts when a paid provider is excluded.
Tiered per-engagement pricing
| Engagement Tier | Output | Turnaround | OIG-eligible fixed fee |
|---|---|---|---|
| T1 - Provider screening | Per-provider triage report + viability score + L1 anchor | 5-10 business days | $3K-$8K per provider |
| T2 - Substantiation | Evidence packet + claim-pattern detection + statutory-element map + UBO pierce | 21-35 days per provider | $20K-$50K per provider |
| T3 - Referral bundle | Court-ready CREB(TM) + deposition prep + expert reference + FRE 902(14) authentication | 14-21 days after T2 | $35K-$90K per provider |
| Continuous exclusion monitoring | Real-time OIG LEIE + state exclusion alert; per-provider eligibility attestation | Real-time | $0.50 per provider per month |
OIG 90% federal cost-share eligible per 42 CFR 1007.20 (subject to your MFCU's approved plan). Statewide annual contracts negotiate to volume-tiered pricing. Year-1 introduction discount for first 3 state MFCUs to sign.
Ready to scope a provider portfolio?
We do a 30-min walkthrough against 2-3 anonymized providers from your historical caseload. You see the T1 output + a sample T2 evidence packet. Most MFCUs use the T1 to prioritize the T2 portfolio.