Payment integrity Overview
Centene · payment integrity
Audit period March 2026 · selection run 02 Apr 2026

7 findings are waiting for a decision.

Standing view of the audit operation. The batch in review covers claims paid in March 2026.

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Awaiting decision
7
of 7 findings · 0 dispositioned
Overpayment identified
$15,288.93
of $87,813.79 reviewed · $0.00 confirmed
Audit hit rate
28.0%
against a 8.0% peer rate · 25 claims screened
Recovery window
0
no finding is close to expiring

Overpayment identified by error type

$15,288.93 in the batch
DRG validation $9,528.92 · 2 findings
Payment above allowable $4,089.23 · 1 finding
Drug units above documented dose $1,344.96 · 1 finding
Medical necessity $254.18 · 1 finding
Duplicate payment $67.71 · 1 finding
Panel unbundling $3.93 · 1 finding

Awaiting your sign-off

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Findings above $1,000.00 need a lead auditor before a recovery letter goes out.

CLM-0000001 Overpayment of $4,089.23 on line 1 $4,089.23 E/M level · 94th percentile CLM-0000013 DRG downgrade — overpayment of $2,956.64 $2,956.64 DRG severity tier · single MCC CLM-0000014 DRG downgrade — overpayment of $6,572.28 $6,572.28 DRG severity tier · single MCC CLM-0000021 Overpayment of $1,344.96 on line 1 $1,344.96 Drug spend · units vs. dose

How the batch was cut

Cost threshold $500.00

Claims are drawn by clinical and cost criteria — what kind of spend this is — rather than by a generic flag. A claim can fall into more than one.

Advanced imaging 3 claims · $762.87 paid
MRI, CT, PET and nuclear studies · 1 finding, $254.18 identified
Drug and biologic 2 claims · $11,153.61 paid
Physician-administered drugs on the medical benefit · 1 finding, $1,344.96 identified
Inpatient admissions 8 claims · $70,167.31 paid
Institutional claims priced by DRG · 2 findings, $9,528.92 identified
Above the cost threshold 12 claims · $86,113.80 paid
Paid above $500.00 · 4 findings, $14,963.11 identified

Exposure that is not a coding finding

Counted apart from the hit rate

A retroactive termination, an unpaid premium or a missing authorization can make a claim recoverable with nothing wrong in how it was coded. Folding those into the finding count would flatter the hit rate; they are tracked here instead.

Up-coded claims 5 · $15,030.82 identified
Down-coded claims 0
Unbundled claims 1 · $3.93 identified
Eligibility at risk 1 · $133.60 paid · CLM-0000005
Authorization gaps 2 · $8,582.64 paid · CLM-0000006, CLM-0000021
Authorizations checked 12 required, 10 matched the claim
Coverage checks run 100 across 25 claims · 4 products · FL, LA, TX

Where the work runs, and where you join it

6 stages

The audit is a pipeline, not a single model. Each stage narrows the batch and hands the next one a smaller, better-evidenced set. An auditor joins at the point where judgement is actually required.

Eligibility and enrolment Runs on its own
Coverage on the date of service, plan and benefit design, primacy and third-party liability — re-verified at audit as well as at adjudication.
100 checks across 25 claims · graph: Enrolment spans, plan benefit design, COB and TPL records · CPP-080
Policy resolution at date of service Runs on its own
The policy version in force on the date of service is resolved and pinned to the claim, so a finding is tested against the guideline that actually governed it.
60 policy references resolved to the version in force on each date of service · graph: Internal policy library, versioned; CMS and state source documents · CPP-080
Selection and scoring Runs on its own
Clinical and cost criteria narrow the paid population — advanced imaging, drug and biologic spend, cost thresholds, DRG severity tiers, duplicate clusters.
25 claims drawn from the paid population · graph: Fee schedules, ASP pricing, MS-DRG weights, MUE ceilings, NCCI pairs · CPP-070
Evidence assembly Runs on its own
Allowables, weights and edits are looked up and cited, each with its source and vintage. Nothing on a finding is asserted without one.
72 cited evidence items across 25 claims · graph: CMS PFS, CLFS, OPPS, MS-DRG v43, NCCI, Part B ASP · CPP-033
Finding and letter drafting Drafted, then reviewed
The agent drafts the finding and the provider letter, with the policy citation and dispute rights already in them. Neither is sent by the agent.
7 findings and 25 letters drafted, none sent · graph: Claim, record extract, resolved policy version · CPP-014
Disposition and sign-off Auditor decides
Confirm, close with no finding, refer to special investigations, or dismiss. Findings above the sign-off threshold need a lead auditor.
0 of 25 dispositioned · 2 authorization gaps referred · graph: — · CPP-085

Knowledge Center

Open the library

The internal policy library every finding in this batch is tested against. Each policy is versioned, and a claim is tested against the version that was in force on its date of service — which, for an audit run months later, is frequently not the version on screen today.

Policies 10 across 6 categories
Versions on file 20
Reached by this batch 9 of 10
Carry a state variation 3
Governed by a superseded version 1 claim · CLM-0000024
What this batch leaned on
CPP-080 Eligibility, enrolment and retroactive termination 25 claims · decisive on 2 v6.1 CPP-047 Inpatient DRG validation — complications and comorbidities 8 claims · decisive on 1 v3.1 CPP-052 Present on admission and hospital-acquired conditions 7 claims · decisive on 1 v2.0 CPP-085 Prior authorization and post-service review 6 claims · decisive on 1 v3.4 CPP-014 Evaluation and management level selection 3 claims · decisive on 1 v4.2 CPP-021 Duplicate and repeat services 3 claims · decisive on 1 v2.3

Policies are synthetic; the external basis each cites is real.

By line of business

Line of business Claims screened With findings Paid Identified
Behavioral health 2 0 $457.32 $0.00
Marketplace 6 1 $5,405.38 $4,089.23
Medicaid 1 1 $254.18 $254.18
Medicaid · TX STAR 6 2 $375.99 $71.64
Medicare Advantage 10 3 $81,320.92 $10,873.88