Amenity

What Amenity does

Amenity Consulting, LLC is a woman-owned small business founded in October 2007 by Kristen Folding and headquartered in Columbia, South Carolina. The firm provides customized healthcare program integrity, fraud-waste-and-abuse (FWA), and claims auditing services to Medicare Advantage plans, Medicaid managed care plans, state Coordinated Care Organizations, commercial health plans, and federal agencies including the Department of Justice, OIG-HHS, CMS, and Medicaid Fraud Control Units. Services span DRG audits, hospital bill reviews, outpatient and APC audits, behavioral health audits, onsite audits, post-acute care audits, NCCI/coding edit reviews, predictive modeling, program integrity support, expert witness and litigation consulting, compliance advisory, and customized training. The company has provided subject matter expert and opinion witness services in federal criminal court and acted in the $65 million Prime Healthcare Medicare false claims settlement.

The firm's core technology stack comprises three proprietary assets: the Claim Selection Engine (CSE), an analytics engine that uses clinical logic and coding analytics combined with plan-specific provider contract language to target aberrant claims for cost containment and recovery; ACES (Amenity Claims Evaluation System), a claim lifecycle tracking platform that tracks each individual claim from audit selection through closure; and Maple Leaf, a system and supporting infrastructure that together with ACES achieved HITRUST Risk-based 2-year (r2) Certification in May 2022 (ACES) and December 2023 (ACES plus Maple Leaf). Predictive modeling capability is described as reverse-engineering plan-specific data for unique data modeling and algorithm development. The company holds HIPAA-compliant IT infrastructure and meets CMS Delegated Entity requirements for each Medicare and Medicaid health plan worked with.

Amenity makes money through customized, quote-based professional services contracts with multi-year engagements, plus managed services delivered via program integrity engagements. Go-to-market is enterprise and government field sales, primarily driven by industry references, word-of-mouth, and direct outreach via the company website and LinkedIn presence. Customer segments are predominantly vertical: Medicare and Medicaid health plans (primary), law enforcement and government agencies, healthcare providers and facilities, and healthcare attorneys handling False Claims Act cases. The company competes on the strength of its credentialed talent (RHIA, CCS, CCS-P, CFE, RN, MSN, R.Ph., J.D., CISSP-certified staff), federal-court-qualified subject matter experts, proprietary technology, and HITRUST certification required for healthcare data handling.

Name

Amenity

Legal name

Amenity Consulting, LLC

Website

https://amenityconsulting.com

Company type

Private

Founded year

2007

Operating status

Operating

Headcount range

11–50 employees

Short description

Amenity Consulting, LLC is a woman-owned healthcare consulting firm that provides customized claims auditing, fraud-waste-and-abuse detection, and program integrity services to Medicare and Medicaid health plans, federal agencies including the DOJ and CMS, and healthcare attorneys handling False Claims Act cases, leveraging proprietary ACES and Claim Selection Engine technology.

Ownership category

akta.pro rank

Product category

Healthcare Program Integrity Services

NAICS

Management Consulting Services (54161), Professional, Scientific, and Technical Services (54)

SIC

Services-Management Consulting Services (8742)

akta.pro primary industry

Risk Management Consulting (Enterprise & Operational Risk) (FSAEADAG)

Keywords

• Healthcare claims auditing
• Fraud waste abuse detection
• Program integrity services
• Medical coding consulting
• Expert witness services

Headquarters

HQ city

Columbia

HQ country

United States

HQ region

North America

Offices1 record

Markets served

GTM type

B2B

Offering type

Services

Cost components

Personnel, Technology or R&D, Operations, Marketing or Sales, Infrastructure

Revenue model

1. Healthcare Claims Auditing Services: Professional services for auditing healthcare claims including DRG audits, hospital bill audits, outpatient audits, and fraud waste and abuse investigations. Services can be prospective or retrospective and are customized to client needs.
2. Litigation and Expert Witness Consulting: Subject matter expert and opinion witness services for DOJ, law enforcement, and qui tam attorneys in healthcare fraud investigations. Includes record reviews, data analysis, settlement activities, and testimony.
3. Training and Consulting: Customized training programs including ICD-10 coding rules, claims processing, DRG audit training, professional coding/billing training, and programming/algorithm development advisory services.
4. Program Integrity Services: Comprehensive program integrity support for CMS objectives, identifying and monitoring program vulnerabilities, collaborating with stakeholders to detect, investigate, and refer fraud cases.

Pricing tiers

Go-to-market motion2 records

Distribution channels3 records

Marketing channels5 records

Core offering

Amenity Consulting provides customized healthcare claims auditing, fraud/waste/abuse detection, and program integrity services for Medicare Advantage plans, Medicaid managed care plans, commercial health plans, state agencies, and federal law enforcement. The firm combines proprietary technology platforms (ACES, CSE, Maple Leaf) with subject matter expertise in medical coding, billing, clinical practice, and data analytics to deliver prospective and retrospective auditing, cost containment, expert witness testimony, and litigation consulting services.

Product overview

Amenity offers a comprehensive suite of healthcare program integrity solutions organized around proprietary technology platforms and specialized service modules. The core technology stack includes ACES (Amenity Claims Evaluation System) for end-to-end claim lifecycle tracking, the Claim Selection Engine (CSE) for targeting aberrant claims, and the Maple Leaf system for fraud monitoring—all supported by HITRUST-certified infrastructure. These platforms are complemented by specialized service modules covering DRG Audits, Fraud/Waste/Abuse (FWA) Audits, Program Integrity, Audit and Recovery, Litigative Consulting, Predictive Modeling, Expert Witness Consulting, Compliance Services, and Training and Consulting. Unlike standardized offerings, Amenity's approach develops customized solutions based on each client's specific needs, initiatives, and business goals, integrating with client network, claims processing, and impacted departments.

Differentiator

Problem solved

Functional benefit

Brands

• ACES (Amenity Claims Evaluation System): Proprietary claim auditing life-cycle tracking system that tracks the life of each individual claim from selection for audit through closure of claim review.
• CSE (Claim Selection Engine)

Products and services

• Audit and Recovery Comprehensive audit services covering administrative accuracy, fraud-waste-abuse, and clinical analytics to address claims administration errors, cost containment, escalating facility charges, inaccurate coding, and medical necessity audits for health plans and government agencies.
• DRG Audits Diagnostic Related Grouper audit services covering all institutional DRG claims with comprehensive understanding of DRG, MSDRG, APDRG, APRDRG payment methodologies and algorithm development for cost containment and recovery for health plans and government agencies.
• Fraud, Waste, and Abuse (FWA) Audits Comprehensive fraud, waste, and abuse assessments categorized through various methodologies by member and provider to assist health plans in ensuring cost containment and investigating abuse and non-compliance.
• Program Integrity Supports CMS Center for Program Integrity objectives promoting integrity of Commercial and Medicare Plans audit and policy review programs, identifying and monitoring program vulnerabilities and collaborating with stakeholders to detect, investigate, and refer fraud cases.
• Predictive Modeling Data analytics service utilizing industry coding knowledge, established pricing tools, and deep experience creating algorithms, reverse engineering data, and building models to mine for cost containment and recovery for health plans and government agencies.
• Litigative Consulting Forensic and subject matter expert services in fraud investigations and litigation including advisory consulting, record reviews, data analysis, settlement activities, Administrative Law Judge Hearings, and trial preparations for law enforcement and attorneys.
• Expert Witness Consulting Expert witness and litigation consulting services providing support to Healthcare Fraud and False Claims Act investigations with federal and state teams, including HEAT efforts, DOJ support, and OIG-HHS investigations across multiple states.
• Compliance Services Compliance services covering federal and state laws, regulations, and contract requirements including guiding management and employees, educating about applicable laws, implementing compliance mechanisms, and meeting CMS Delegated Entity requirements.
• Training and Consulting Industry-specific curriculum development, ICD-10 coding training, operational impact education, claims processing training, DRG audit training, professional coding/billing training, and specialty physician advisor support.

Quantifiable outcome

• Subject matter expert involvement in $65 million Medicare false claims settlement
• +3 more outcomes

Named customers9 records

Segments4 records

Ideal customer profiles3 records

Technology focussed No

API detail

Has API

No

API docs

API detail

Core technology

AI maturity

App detail

Feature4 records

Partnerships

Seven partnerships are on record, tiered core, flagship and minor.

• Chase Consulting, LLCcoreImplementation/ SI/ Consulting Partner · 1 September 2015Amenity is a subcontractor to Chase Consulting, LLC on the CMS Probable Fraud Measurement Pilot (PFMP). The program estimates the incidence of potential Home Health Care fraud in the Medicare fee-for-service program through data mining, field interviews, and medical record reviews.
• Department of Justice (DOJ)flagshipStrategic or Co-development PartnerAmenity has been retained as subject matter expert and opinion witness for the DOJ in healthcare fraud investigations. Most notably in the $65 million Prime Healthcare settlement for Medicare false claims involving up-coding and medically unnecessary admissions. Staff have acted in capacity of Litigative Consultant and Opinion Witness to law enforcement including DOJ in Washington, DC.
• US Attorney/OIG-HHS OfficescoreStrategic or Co-development PartnerStaff have acted in the capacity of Litigative Consultant and Opinion Witness to 19 US Attorney/OIG-HHS Offices in 16 states. Amenity has provided subject matter expertise to Qui Tam attorneys in cases where the government has intervened and civil cases.
• Medicaid Fraud Control Units (MFCU)coreStrategic or Co-development PartnerAt the state level, Amenity works with Attorney Generals and Medicaid Fraud Control Units in conjunction with active law enforcement investigations for program integrity enforcement.
• Zone Program Integrity Contractors (ZPIC)minorStrategic or Co-development PartnerWorked alongside ZPIC, Program Safeguard Contractors (PSC), and Medicaid Integrity Contractors (MIC) in program integrity efforts.
• Healthcare AttorneyscoreStrategic or Co-development PartnerAmenity provides expert witness and litigation consulting services to healthcare attorneys on behalf of commercial and managed Medicare and Medicaid plans, as well as Qui Tam attorneys in government-intervened and civil cases.
• Department of Veterans Affairs (VA) Foreign Medical ProgramminorStrategic or Co-development PartnerAmenity provides subject matter expert in international criminal fraud case involving Panamanian doctors and pharmacies submitting false claims to the VA's Foreign Medical Program, expected to save $25 million.

Scale indicators6 records

Recent moves6 records

Expansion highlights6 records

Broad incumbents

• Optum (UnitedHealth Group): Optum is a massive healthcare analytics, consulting, and payment integrity platform serving payers and federal programs; it competes with Amenity broadly across claims auditing, FWA, and program integrity, though at far greater scale.
• Cognizant TriZetto: Cognizant's TriZetto healthcare division provides claims processing, payment integrity, and consulting for payers, representing a broader-incumbent alternative to Amenity's specialized audit and FWA services.
• Change Healthcare: Change Healthcare (now part of Optum) is a large healthcare data, analytics, and revenue cycle platform offering payment integrity and fraud detection capabilities that overlap with Amenity's claims analytics services.
• Gainwell Technologies: Gainwell Technologies (successor to HMS) is a large government healthcare services and program integrity vendor serving state Medicaid agencies and CMS, overlapping with Amenity's Medicaid managed care and federal program work.
• SCIO Health Analytics: SCIO Health Analytics (now part of EXL) provides payer-focused analytics including payment integrity and FWA services, overlapping with Amenity's healthcare program integrity and predictive modeling capabilities.

Direct peers

• CGI Federal: CGI Federal is a major IT and consulting services contractor for CMS and federal healthcare programs, including program integrity work; it competes with Amenity for federal healthcare fraud, waste, and abuse contracts.
• EXL Health: EXL Health provides payment integrity, fraud waste and abuse analytics, and care management services to payers, directly overlapping Amenity's FWA auditing, predictive modeling, and program integrity offerings.
• ClarisHealth: ClarisHealth is a healthcare payment integrity vendor offering FWA detection, post-pay and pre-pay auditing, and analytics for health plans, competing with Amenity in the same payer-facing claims auditing niche.
• Cotiviti: Cotiviti is a leading healthcare payment integrity and claims accuracy firm serving major health plans with prospective and retrospective auditing, fraud detection, and analytics — the closest scaled direct competitor to Amenity's core FWA and audit services.
• Healthcare Fraud Shield: Healthcare Fraud Shield provides FWA detection software and analytics for Medicare Advantage, Medicaid, and commercial health plans, overlapping Amenity's FWA auditing, predictive modeling, and claim selection capabilities.

Market position

Strengths5 records

Weaknesses5 records

Competitive moat4 records

Key risks6 records

Key highlights7 records

Customer concentration

• Facebookfacebook.com/amenityconsulting
• LinkedInlinkedin.com/company/amenity-consulting-llc

Compliance3 records

Revenue estimate

Valuation estimate

Number of profiles

Profiles7 records

Funding overview

Funding rounds

Investors

Funding detail is available on the Subscription and Enterprise plan.Contact sales →

M&A

Investments

M&A and investment is available on the Subscription and Enterprise plan.Contact sales →

Frequently asked questions about Amenity