Sentinel Solutions
36 fraud vectors. 8 lifecycle stages. Four prime federal databases. 150M+ Medicaid claims of evidence. The Medicaid integrity platform built to prove it, not just flag it.
36 fraud vectors. 8 lifecycle stages. Four prime federal databases. 150M+ Medicaid claims of evidence. The Medicaid integrity platform built to prove it, not just flag it.
36 fraud vectors mapped to 20 IG audit findings across 8 program integrity lifecycle stages, $800M to $2B+ in estimated annual exposure per state
Fraudulent credentials, false affiliations, excluded provider re-enrollment, shell entities
Ineligible individuals, income misrepresentation, duplicate enrollment across programs, identity fraud
Unauthorized services, level-of-care manipulation, prior auth bypass, unnecessary referrals
Upcoding, unbundling, phantom billing, duplicate claims, misrepresented services
Fee schedule violations, incorrect rate application, missed edits, policy override abuse
Duplicate payments, overpayments, payment to ineligible entities, vendor kickback patterns
Pattern detection, recovery identification, network analysis, outlier flagging
Audit trail documentation, regulation mapping, cross-program compliance, federal reporting
Upcoding, unbundling, duplicate billing, phantom services, misrepresented place of service, date of service manipulation
Credential fraud, excluded entity enrollment, identity theft, kickbacks, self-referral violations, shell company networks
Eligibility misrepresentation, identity fraud, duplicate enrollment across programs, out-of-state coverage
Capitation overpayment, encounter data manipulation, cost avoidance, subcontractor misuse, access standard violations
Multi-program double-dipping, data mismatch between agencies, benefit stacking abuse, coordinated fraud rings
Authorization bypass, claims system abuse, data integrity violations, reporting manipulation
Before federal data integration, platforms detected patterns in claims data. Sentinel validates those patterns against federal ground truth. Every claim checked against ICD-10-CM codes (catches upcoding), NPI Registry (catches ghost providers), and CMS Coverage Determinations (proves whether MCO denials comply with federal rules).
Our 36 fraud vectors aren't theoretical, they're mapped directly from the October 2025 Kansas Medicaid IG performance audit (154 pages) and cross-referenced against 20 specific audit findings. Every vector has a dollar-exposure estimate, a detection methodology, and an evidence standard. $800M to $2B+ in estimated annual exposure across all vectors.
When an MCO denies a Medicaid claim, we cross-reference that denial against the CMS Coverage Determination that governs the service. If the LCD says covered and the MCO denied it, that's provable non-compliance, not a clinical judgment. We produce compliance scorecards for every MCO that state agencies and OIGs can act on immediately.
Identify underpayments, denials, and optimization opportunities across all programs
Sentinel identifies recovery opportunities and prioritizes them by revenue impact and actionability. Recovery execution is available through High Value Change operational partners (appeals, provider outreach, claims resubmission), or states can action findings in-house with full Sentinel documentation.
Typical ROI: $5-$8 recovered for every $1 spent on Sentinel oversight.
Real-time program integrity visibility across every funded program
Deep-domain monitoring capabilities tailored to each program area
Three MCO provider manuals deconstructed and compared (Kansas: Sunflower, UHC, Healthy Blue). Collection rate disparities quantified: 72.3% vs. 54.1% for comparable services. Hospital claims = 6 to 7% of denied count but 64 to 67% of denied dollars. Every denial cross-referenced against CMS LCD/NCD coverage rules.
Placement payment verification, provider licensing compliance, caseworker caseload analysis, congregate care rate audits, independent living program outcomes, Title IV-E claiming accuracy.
Retailer fraud detection, EBT trafficking patterns, eligibility verification against employment data, duplicate participation across states, vendor compliance monitoring.
Claimant eligibility verification, employer fraud detection, training program outcome tracking, cross-state claims matching, identity verification for UI benefits.
Service verification against treatment plans, provider credential monitoring, outcomes-based compliance, duplicate billing across behavioral health and Medicaid, opioid treatment program oversight.
Tenant eligibility verification, landlord payment accuracy, supportive housing outcomes tracking, coordinated entry data integrity, HUD compliance monitoring.
Every program has unique fraud signatures, compliance requirements, and payment structures. A one-size-fits-all approach misses program-specific patterns that cost states billions. Sentinel deploys domain-specific detection models for each program area, with capabilities already proven in active state deployments.
Sentinel's agency-specific oversight capabilities are deployed today as part of active state grant programs, with measurable results: millions in recoverable revenue identified within the first year of operation.
National evidence. State rules. Your data. Designed for national deployment.
150M+ Medicaid claims across multiple years, 207,638 CMS coverage determinations, 98,186 ICD-10-CM codes, 8,962+ verified provider NPIs, 35M+ PubMed articles. All pre-loaded and applicable to any state. This is the evidence base that transforms every finding into a provable case, the deepest independent Medicaid claims intelligence in the country.
State-specific MCO rules, fee schedules, regulatory landscape, and IG audit findings. MCO provider manuals deconstructed and compared. Denial pattern baselines established. Capitation-to-eligibility alignment validated. Built per state in weeks, not months, the only state-specific component in the architecture.
Organization-specific claims data, denial patterns, CARC/RARC analysis across 393 denial categories, and MCO compliance scorecards grounded in federal evidence. Every MCO denial cross-referenced against the CMS coverage determination that governs it. Collection rate disparities quantified. Capitation-to-service delivery gaps exposed.
We process and correlate data from the most authoritative sources
Medicare/Medicaid fraud databases, OIG exclusion lists, NPPES provider data, fee schedule corrections
Claims, eligibility, enrollment, authorization, and case management data across Medicaid, SNAP, TANF, child welfare, and workforce programs
Encounter data, capitation payments, subcontractor records, provider credentials, managed care fee schedules
SNAP retailer databases, EBT transaction patterns, FNS compliance data, retailer authorization records
UI claims data, employer records, wage verification, training program enrollment, cross-state employment records
State program policies, CMS waiver terms, federal guidelines, managed care contracts, administrative rules
IRS 990 nonprofit filings, CMS Open Payments, OIG reports, state legislative records, SAM.gov exclusions, FPDS contracts
835 ERA files, claim-to-payment reconciliation, denial reason codes, payment adjustments, EFT confirmations
The 36 fraud vectors are universal. The federal databases are national. The only state-specific component is the regulatory overlay, and that can be built in weeks. Talk to David about what Sentinel can uncover in your state.
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