FEDRAMP ALIGNED · OIG · CMS · NIST 800-53 · HIPAA · RAC · SOC 2 TYPE II

Forensic Data Integrity & Audit Defense

Forensic Auditing That Secures Revenue—Not Just Paperwork.

QMTRY Audit Section
  1. RevCycleMGMT’s forensic team defends your Provider revenue integrity end-to-end. We target high-stakes audit risks including RAC (Recovery Audit Contractors), TPE (Targeted Probe & Educate), and Commercial Payer Clawbacks, shifting the focus from passive reporting to active defense.
  2. We execute deep-tier validation on 837/835 EDI streams: pinpointing root causes of Denials and DNFB (Discharged Not Final Billed) waste; verifying Clinical Documentation Integrity (CDI) against CMS coverage determinations (LCD/NCD); and hardening data lineage for federal scrutiny.
  3. Every finding evolves into an Audit Evidence Pack—automated appeal letters, substantiated medical necessity arguments, and traceable data lineage. We track closure with financial KPIs: ↓ Denial Rate, ↑ Clean Claim Yield, ↑ Net Collection Ratio, and ↓ Days in A/R.
QMTRY Providers Table
Providers — Problem Spaces
Revenue & Cash (Denials)
Problem Signals
  1. Margin pressure; rising denials
  2. Slow cash; DNFB growing
  3. Confusing payer rules
QMTRY Services
  1. Rev-cycle & payment-integrity analytics
  2. 835/837 recon; CARC/RARC mapping
  3. Coding & compliance QA
Tangible Deliverables
  1. Denial heatmaps & playbooks
  2. A/R auto-work queues
  3. Audit-ready RCM dashboards
Impact / KPIs
  1. ↓ Denial rate, ↓ DNFB
  2. ↑ Clean-claim rate
  3. ↑ Cash yield
Quality / Stars & VBC
Problem Signals
  1. Weak HEDIS/Stars performance
  2. Care gaps not closing
  3. VBC readiness uncertain
QMTRY Services
  1. HEDIS/Stars analytics & measure build
  2. Gap-closure stratification & outreach
  3. Provider performance coaching
Tangible Deliverables
  1. Member gap lists & chase files
  2. Measure run-rates & cohort drilldowns
  3. Provider scorecards
Impact / KPIs
  1. ↑ Gap closure %
  2. ↑ Measure compliance
  3. ↑ VBC shared savings
Data & Interoperability
Problem Signals
  1. Fragmented EHR data
  2. ADT/CCD/FHIR issues
  3. Slow feed onboarding
QMTRY Services
  1. FHIR integration & ingestion
  2. Canonical data model & ELT
  3. Data quality checks (GX)
Tangible Deliverables
  1. Data dictionary & lineage map
  2. Validation logs & exceptions queue
  3. Run-books & diagrams
Impact / KPIs
  1. ↓ Data defects
  2. ↓ Time-to-insight
  3. Faster onboarding
Compliance & Audit
Problem Signals
  1. HIPAA/NCQA audit risk
  2. Missing model/process evidence
  3. Access control gaps
QMTRY Services
  1. Continuous compliance monitoring
  2. Evidence bundle generation
  3. Access & activity auditing
Tangible Deliverables
  1. Model cards & KPI definitions
  2. Audit logs & control matrices
  3. Risk register & remediation
Impact / KPIs
  1. Audit-ready artifacts
  2. ↓ Findings / exceptions
  3. Policy → evidence traceability
Pharmacy Adherence
Problem Signals
  1. Medication adherence issues
  2. SUPD outliers
  3. PDC below target
QMTRY Services
  1. PBM & pharmacy analytics
  2. Adherence program design
  3. Refill / outreach segmentation
Tangible Deliverables
  1. PDC distributions & risk tiers
  2. SUPD lists (member/provider)
  3. Outreach queue exports
Impact / KPIs
  1. ↑ PDC
  2. ↓ SUPD gaps
  3. ↑ Drug-measure STARS

Forensic Control Mapping

We map billing patterns directly to CMS Local Coverage Determinations (LCDs), NCQA standards, and OIG Work Plan priorities. No “tribal knowledge”—just a living control map that flags TPE audit triggers and compliance gaps before they become clawbacks. Widget: Button Text: View Control Map

See Evidence Flow

Zero-Trust EDI Governance

 Our pipelines enforce strict validation on every 837 claim and 835 remittance. We detect schema errors, logic gaps, and data drift in real-time—ensuring that the data feeding your financial reports is technically validated and legally defensible. Widget: Button Text: See Pipeline Logic

See Evidence Flow

Audit Evidence Bundles

Generate regulator-ready exports in minutes. From automated appeal letters to timestamped policy logic and lineage logs, we deliver the substantiated proof required to defend against commercial and federal auditors. Widget: Button Text: Request Sample Bundle

Request Sample Bundle

Forensic Payer Audits That Enforce Integrity, Stop FWA, and Drive Quality

RevCycleMGMT Forensic Value Chain
  1. We forensic-test the revenue cycle end-to-end— validating 837/835 EDI streams against CMS coverage policies (LCD/NCD); hardening Clinical Documentation Integrity (CDI) for TPE/RAC audits; and detecting Fraud, Waste, & Abuse (FWA) patterns before the OIG does.
  2. Findings don’t sit in spreadsheets: we convert them into automated appeal packets, payment variance reports, denial root-cause heatmaps, substantiated medical necessity arguments, and audit-ready evidence bundles traceable to source data.
  3. The result is revenue integrity that withstands scrutiny: ↓ TPE failure rates & clawbacks, ↑ Clean Claim Yield & Net Collection Ratio, ↓ improper payment risk, and 100% lineage visibility for federal compliance.
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From Signals to Proof—Fast.

We turn provider and payer noise into audit-ready operations: denials down, Stars/HEDIS up, TAT down—backed by evidence you can hand to an auditor or a CFO without blinking.

  • Providers: ↓ denials & DNFB • ↑ clean-claim rate & cash yield • ↑ HEDIS/Stars • ↓ time-to-insight
  • Plans: ↑ overall STAR rating & bonus eligibility • ↓ improper payments & penalties • ↑ first-pass accuracy • ↓ TAT/backlogs
  • Signals → Services → Deliverables → KPIs — plumbing stood up, worklists live, evidence bundled.
  • Artifacts: heatmaps, driver trees, gap lists, edit-rule packs, scorecards, model cards, lineage, and a one-click Audit-Ready Pack.
Stars/HEDIS Sprint Denials Triage Audit-Ready Pack

Stars/HEDIS Sprint (4–6 weeks)

Baseline → top 5 fixes → outreach queues → live scorecard.

Open Stars/HEDIS Sprint Repo

Denials Triage (30 days)

Top 10 root causes → A/R auto-queues → yield KPIs you can track.

Open Denials Triage Repo

Payer Ops Throughput

Intake-to-outcome maps → TAT dashboard → automation shortlist.

Open Claims Pipeline Repo

Controls & Measure Mapping

Map HIPAA/HITECH, NCQA/HEDIS, and CMS Stars to org & stack. Assign owners, SLAs, and tests so policy ⇢ control ⇢ evidence isn’t “tribal knowledge.”

Open Controls Mapping Repo

Continuous Evidence & Data QA

Pipelines (dbt + Great Expectations) emit tests, approvals, lineage, and exceptions as they run—one source of truth, not screenshots.

Open Evidence Pipelines Repo

Audit-Ready Evidence Pack

One export: policies, control map, test runs, KPI definitions/model cards, screenshots, and sign-offs—timestamped and navigable.

Open Evidence Pack Repo

Evidence, Not Screenshots

KPI Dictionary & Model Cards

Every metric defined, versioned, and tied to its source.

Open KPI Repo

Lineage & Data Contracts

From FHIR/HL7 ingest to dashboard—tracked and testable.

Open Lineage Repo

Control Map & Tests

Policy → control → test → run history, all in one trail.

Open Controls Repo

Audit-Ready Pack

A single, timestamped export for auditors & execs.

Open Evidence Repo
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