We don't just find fraud. We prove it, with 150M+ Medicaid claims and four prime federal databases.
36 fraud vectors. 8 lifecycle stages. $800M to $2B+ in annual exposure mapped to Inspector General findings. The Medicaid integrity platform built to hold MCOs accountable and deliver action-ready oversight intelligence.
Operationalize MCO oversight with audit-ready evidence packs and federal coverage rule cross-references.
For State Government ›Prosecution-grade case files built on federal coverage determinations and MCO denial pattern intelligence.
For MFCUs ›Litigation-ready evidence for MCO accountability actions, false claims recoveries, and parens patriae work.
For Attorneys General ›Findings that convert to enforcement, not acknowledgment. Federal and state oversight workflows supported.
For OIGs ›Analytics layer aligned to CPI's audit, vulnerability, data analytics, provider compliance, and contractor oversight functions.
For CMS / CPI ›Multi-state baseline data, exposure modeling, and audit-ready evidence for oversight hearings and GAO reviews.
For Federal Oversight ›Plug-in managed-care program integrity analytics layer that extends your existing scope and reduces analytic burden.
For MMIS Primes ›Medicaid MCO denial pattern intelligence to complement Medicare program integrity scopes with state-side evidence.
For UPIC Primes ›Evidence-ready workpapers for state Medicaid accountability engagements, audit support, and IG response work.
For Consulting Primes ›One Kansas MCO ran a greater than 50% prior authorization denial rate. That concentration isn't random. It's structural. And no one is cross-referencing those denials against federal coverage rules. Until now.
A recent state IG performance audit named $193M in HCBS payments to potentially inactive beneficiaries, proprietary PA tools creating conflicts of interest, and systemic denial patterns.
Agency response to most findings: "acknowledged, no action taken."
Even in states that find the overpayments, the gap between finding and recovering is structural. The problem isn't a lack of fraud. It's a lack of intelligence infrastructure to prove it and operationalize the recovery. Every other oversight body in this country has the same gap, and almost none of them know what it costs them every year.
When an MCO denies a Medicaid claim, Sentinel cross-references that denial against the actual CMS Coverage Determination that governs the service. If the LCD says covered and the MCO denied it, that is provable non-compliance, not a hunch.
Every fraud vector has a federal checkpoint. Sentinel validates patterns against federal ground truth, not just statistical anomalies.
We don't just read IG audits. We operationalize them, turning findings into measurable accountability metrics that oversight committees can track quarter by quarter.
Enterprise PI vendors sell to MCOs. Sentinel sells to the agencies that oversee MCOs. Same data, opposite incentive.
Every state has an Inspector General. Every state has an MFCU. Every state has a legislative oversight committee. None of them has the cross-referenced federal evidence stack required to make MCOs answer for what their own data already proves.
Sentinel as the named program-integrity intelligence vendor to a state OIG, AG MFCU, state Medicaid PI director, or legislative oversight committee. Full seven-module stack deployed against your jurisdiction with quarterly committee reporting.
Best fit: state agencies with statutory data-access authority and a procurement vehicle. Kansas HB 2513 Sec. 32(a) is the active example.
The managed-care program-integrity analytics layer for UPIC contractors, federal CMS analytics primes, HHS-OIG support contractors, state MMIS primes, MFCU support primes, and major consulting firms holding state Medicaid engagements. We complement, never compete with, your existing scope.
Best fit: primes that need the state-oversight-of-MCO analytics layer their existing platform does not field. For Prime Contractors page →
A fixed-scope 30-to-90-day engagement against one or two named use cases: MCO denial outliers, HCBS ghost-enrollment, deceased capitation, school-based dual-payment, or any of the 34 vector-library priorities. Produces a written findings report, dollar-at-risk estimate, and a path to broader engagement.
Best fit: agencies that want proof before broader procurement, or primes that want a focused subcontract pilot.
See exactly what's happening across every funded program: one view, every MCO, every vector.
Sentinel operationalizes the data CMS publishes, turning it into actionable fraud prevention and MCO accountability intelligence.
Six layers, one pipeline. State and prime delivery workflows feed directly into the procurement-ready outputs your team can stand behind.
David Thorne is the founder and CEO of Sentinel Integrity Group, a Division of High Value Change. He leads Sentinel's Medicaid managed-care program integrity platform, holding MCOs accountable to the federal coverage rules that govern the services they are paid to deliver. A graduate professor of Digital Transformation at Wichita State University's Executive MBA program, David developed the DDR (Discovery, Diagnostics, Roadmap) methodology, a repeatable digital transformation framework grounded in Christensen's innovation theory. Before founding his current firms, he spent nearly a decade at Boeing as a Program Manager leading M&A integration across billion-dollar business units, earning a Malcolm Baldrige National Quality Award and multiple Wichita Business Journal Innovator of the Year recognitions. He is the author of Stealing Clarity, a forthcoming book on data integrity and the behavioral science of organizational change.
Medicaid managed-care program integrity analytics. 36-vector fraud library mapped to Inspector General findings. 8-stage claims lifecycle forensics. Federal coverage rule cross-referencing: NCDs, LCDs, and Medicare contractor determinations applied to Medicaid MCO denial patterns. MCO accountability scoring and audit-ready evidence packs. State-level exposure modeling, $800M to $2B+ annual per state.
State Medicaid Agencies · Medicaid Fraud Control Units · State Attorneys General · State and Federal Inspectors General · CMS Center for Program Integrity · GAO and congressional oversight · MMIS, UPIC, and consulting primes.
Subcontract to prime contractors as the managed-care program integrity analytics layer. Sentinel extends existing scopes, supports incumbent delivery teams, reduces analytic burden, produces evidence-ready workpapers, and integrates into prime workflows.
40+ states. Hundreds of MCOs. $400+ billion in annual Medicaid spending. The fraud vectors, MCO accountability gaps, and oversight failures Sentinel identified in Kansas are structural. They exist in every managed-care state because the incentive misalignments are identical.
Schedule a 30-Minute Integrity Assessment