PI-002 ยท Regulated consumer programs
Eligibility, enrollment and benefit continuity
A channel marker that had quietly moved.
Presenting problem
We examine enrollment, device, eligibility, credit, and reimbursement records to uncover incomplete data, broken transaction histories, and activity that never received the proper financial treatment.
What brought us in
Two oversight reviews reached opposite conclusions about the same program period. Neither could be reconciled against the other.
What the client believed
That the disagreement was a definitional dispute between reviewers about how to count an enrollment.
What the evidence showed
The two reviews had counted different populations because eligibility was recorded in one system, renewal in another, and payment in a third. Each was defensible alone. Combined, they described enrollments that could not simultaneously be true.
How the examination proceeded
Method applied to this engagement.
- 01Preserved eligibility determinations, renewal records, payment files and case notes with custody recorded at intake.
- 02Rebuilt each enrollment as a continuous timeline of determinations rather than a current status.
- 03Identified payment periods with no supporting determination in force.
- 04Separated administrative lapse from substantive ineligibility, because the two carry different remedies.
- 05Quantified each category separately and stated the boundary between them explicitly.
Substantiated findings
What the records support.
A measurable population received payments during periods when no eligibility determination was in force.
Substantiated - documentaryThe majority of that population reflects administrative lapse rather than substantive ineligibility, which changes the remedy but not the exposure.
Substantiated - qualifiedThe two prior reviews are both arithmetically correct and are not comparable, because they measure different populations.
Substantiated - reconciliationExposure
130k+ records examined, $9m+ in device value
Figures are rounded and generalized for publication. In delivery, each figure is deterministic and carries its inputs, calculation version and population definition.
Control failure map
Why it was possible.
- Renewal deadlines were tracked operationally but were not tied to payment authority.
- No single record of determination history existed across systems.
- Oversight reviews used populations that were never defined in writing.
Outcome
What the client did with it.
- A single reconciled population definition delivered and adopted for future reporting.
- Remedy split allowed recovery effort to be directed where it was legally supportable.
- Evidence package prepared to a standard suitable for external oversight.
Each population boundary in the report is traceable to the determination records that define it, with every original preserved.
