02Program Integrity & OIG
Detection, prevention, and recovery built into the operating model — not bolted on.
Program-integrity and Inspector General offices were designed for a post-payment world: detect the improper payment, claw it back, report the aggregate. Contemporary improper-payment defense moves earlier in the lifecycle — at intake, at adjudication, at provider enrollment. We help OIG and program-integrity offices reach where the dollars actually leave.
- Federal improper payments — annual
- $233B+
- Investigator caseload per FTE
- 200–1,000 active
- Recovery vs. prevention ratio
- Heavily recovery
01What we keep seeing
Three failure modes that pre-date the AI conversation.
01
Tip queues swamp investigator capacity
Most OIG offices triage tips by date received. Investigators spend the first 30% of every case ranking the queue before they begin the work. A correctly ranked queue would save a third of an FTE per investigator.
02
Recovery dominates the resource pool
Three quarters of program-integrity FTEs sit on the recovery side. The provider-overbilling that caused the issue was detectable at the moment of the first overbilled claim — twelve months and a few thousand claims earlier.
03
Cross-program fraud rings are invisible to single-program agencies
A ring exploiting SNAP, Medicaid, and UI simultaneously is detectable from any one of those programs in isolation only weakly. Joined, the signal is overwhelming. Few states join the data.
02How we work the seam
Specific practices. Specific outcomes. No platitudes.
Practice 01
Outcome
30–60% recovery lift on the same investigator capacity
Expected-recoverable-value queue ranking
Replace date-ordered tip queues with expected-recoverable-value ranking. Combine signal strength, dollar exposure, statute-of-limitations runway, and recoverability into a single score. Investigators work the top of the queue first.
Practice 02
Outcome
Catch the first-month outlier, not the twelfth
Provider-overbilling early-detection
Sequence models on provider claim patterns flag the first month of overbilling. Combined with peer-group benchmarking and prior-period baseline shifts, the signal can be acted on before $100K is out the door, let alone $10M.
Practice 03
Outcome
Surface rings invisible to single-program agencies
Cross-program identity-graph correlation
Construct a unified claimant identity graph across SNAP, Medicaid, UI, TANF, and the state tax filings. Rings that exploit multiple programs become detectable; legitimate users get cleaner cross-eligibility flows as a side benefit.
Practice 04
Outcome
Recoveries withstand appellate review
Adverse-action notices that survive challenge
Every adverse action — recoupment, suspension, exclusion — needs counsel-reviewed notice copy and per-decision provenance. The recovery is only as durable as the documentation.
03Market scale
The size, growth, and obtainable share of this market.
Every benefits-decisioning segment shares the same pattern: program dollars in the hundreds of billions, services spend in the single-digit billions, modernization and detection investments compound across the program spend.
TAM
$233.0B
Program dollars in scope
SAM
$4.1B
Annual services spend
5-yr CAGR
9.4%
Rolling SAM growth
3-yr SOM
$95M
Vardr-obtainable
Vardr captures a small but compounding share of the addressable services spend; the underlying program dollars dwarf the modernization budget.
GAO and HHS-OIG improper-payment series. SAM = consulting + detection-services spend across federal and state OIGs. SOM = 3-yr Vardr-obtainable.
5-year SAM growth — Program Integrity & OIG
$4.1B → $6.4B
04Programs we focus on
Program integrity, Inspector General, and recovery operations.
CMS Center for Program Integrity / State OIG
Medicaid program integrity
Provider screening, payment integrity, post-payment recovery, exclusion-list monitoring.
USDA FNS / State SNAP agency
SNAP retailer + claimant integrity
Retailer trafficking detection, EBT-issuance fraud, claimant-side eligibility integrity.
DOL ETA / State UI agency
Unemployment-insurance integrity
Synthetic-identity defense, fictitious-employer detection, post-pandemic program-integrity rebuilds.
State OIG
State Inspector General offices
Tip triage, recovery queue, cross-agency referrals, prosecution package assembly.
05Questions worth asking
Open these with us — or with anyone else.
We bring these to every program-office conversation. Use them whether or not we end up working together.
- 01
What share of program-integrity FTEs sit on prevention vs. recovery? Where would the next FTE produce the higher return?
- 02
Is your tip queue ranked by expected recoverable value, or by date received?
- 03
Can your provider-overbilling detection act on a first-month outlier, or only on a twelve-month pattern?
- 04
Does the agency maintain a unified claimant identity graph across SNAP, Medicaid, UI, and TANF, or are those program datasets siloed?
06Related insights
Working in program integrity & oig and want our take?
45-minute principal-level briefing. Bring the program, the constraint, the deadline.