FRAUD MANAGEMENT

Fraud Management Solutions
HCRG is a leading provider of solutions specifically designed to fight fraud. Utilizing claims data analytics, Medicare, Medicaid and payer rules, CPT code analysis, medical evidence based criteria, and medical entity business management intelligence, we engineer our solutions to detect fraud patterns, abusive billing practices, over-utilization and misrepresentation services or services provided. We work with payers to identify, manage, and prevent fraud.

Our fraud management services include:
• Consultation.
• Education.
• Fraud detection.
• Post pay analysis.
• Pre pay analysis.
• SIU partnership.
• Litigation support.
• Evidence preparation.
• Data analatics.
We have Special capability to handle to complex and addiction and sober living cases.

Our Mission
We partner with payers and their SIU teams to:
• Produce value added billing and service specific analysis , reviews and consultation to maximize the effectiveness or identifying and figuring fraud.
• Analyze CPT code utilization with clinical documentation, medical necessity evaluation, fraud alerts, and develop evidence based fact driven tools to support the SIU team in the execution of their work.
• Be a reliable source of continuous consultative support and education to the payers and their SIU teams on medical management, healthcare business practices and fraud trends.
• Provide tools required to fight case.

Our Team
Our team is specifically prepared for the task. They are not only trained in medical reviews and analysis but they are also trained in:
• Medical billing and coding.
• Integration or CPT code analysis with clinical documentation and medical necessity determination.
• Fraud identification, detection and investigation.

Team Qualifications
Our team is composed of:
• Management experts
• Medical Doctor specialists
• Registered nurses
• Certified specialty coders
• Certified utilization reviewers
• Research assistants
• Technical administrative assistants
• Information technology specialists

Team Capacity
We are able to expand our team based on the needs of our clients. Our medical reviews focus on the detection of:
• The appropriateness of billing.
• Incorrect reporting of diagnoses.
• Billing unnecessary medical services.
• Over-utilization of services.
• Misusing of codes: upcoding, unbundling.
• Billing for services not rendered.
• False billing.
• Illegal practice of Medicine.
• Misrepresenting services provided.

Review Scope
Our extensive review scope include:
• Hospital care
• Inpatient Rehabilitation
• Convalescent home
• Nursing home
• Home personal care
• Addiction medicine
• Physician practices/all specialties
• Laboratory
• Radiology
• Pharmacy/medication
• Home health
• Surgical care services/all specialties
• Medical care services/all specialties
• Sober living
• Pain management
• And more…
We are prepared to work on any type of service.

What makes us different?
• Our extensive experience in healthcare fraud.
• Our ability to conduct a broad scope of service review.
• Our ability to work with complex cases.
• Our ability to utilize claim and review data to profile a provider practice pattern.
• Our knowledge and experience in fraud management.
• Our best in class fraud management solution.
• Our ability to partner and work well with the SIU team.

Our deliverables
• Customized reports per clients request.
• Medical necessity reports.
• Data validation reports.
• Timely delivery of reports.
• Consulting
• Education


Customer Service
Call:  (562)-945-7224

Corporate Address:  
6571 Altura Blvd.,
Buena Park, CA 90620

“HCRG can customize a
Case Management program according to client needs.”