FRAUD MANAGEMENT

SIU Medical Review Services
HCRG is a leading provider of medical review 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 reviews 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.

SIU Medical Review Program
HCRG has designed and implemented a Medical Review program to meet the needs of the payers and their SIU teams to fully enable them to identify, investigate and when possible, assist in the precaution of those individuals and entities that commit fraud against the healthcare delivery system. The scope of our Medical Review service include:
• Multiservice complex medical chart review.
• Analysis of CPT code utilization.
• Analysis of billing practice.
• Analysis of billing and medical necessity.
• Diagnosis validation.
• Utilization of medical service needs.
• Utilization of drug needs.
• Misrepresentation of clinical documentation analysis.
• Medical necessity determination.
• Fraud, abuse and waste evaluation.

Our Mission
We partner with payers and their SIU teams to:
• Produce value added billing and service specific medical reviews 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.

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

Team Qualifications
Our team is composed of:
• Management experts
• Medical specialists
• Registered nurses
• Certified specialty coders
• 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:
• Hospital care
• Inpatient Rehabilitation
• Convalescent home
• Nursing home
• Home personal care
• Adult day care
• Drug Recovery
• Physician practices/all specialties
• Laboratory
• Radiology
• Pharmacy/medication
• Home health
• Surgical care services/all specialties
• Medical care services/all specialties
• DME
• Pain management
• And more…
We are prepared to conduct any type of review.

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

Our deliverables
• Customized retrospective review reports.
• 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.”