SIU Support Services

Medical Reviews, Claim Audits, Evidence Documentation of FWA, Litigation Support and Preparation, Site Inspection, Education, Litigation Strategy Consulting.

The payer SIU team is charged with investigating allegations of fraud and take actions to litigate them. The investigative actions are very involved and may include data analysis to identify outlier billing patterns, public record reviews to determine professional and business licensures and Medical Records Review. They may have to evaluate internal systems - such as credentialing file, provider contract, prior authorizations, etc. They may have to conduct interviews, provider onsite audit and request medical records reviews by coder, nurses, and/or medical doctors. Once a determination has been made that the target party has engaged in FWA, appropriate remdeial actions are pursued. Documentation and gathering of evidence may be required along with recoupment efforts.

HCRG provides all these required services. We work alongisde the payer SIU teams to assist them in investigating, litigating and education. We have expertise in many complex areas.

SIU Support Services include:

• Medical Records Reviews
• Complex Medical reviews to confirm data analytics findings
• Detect Risk Areas in coding, billing, care management, documents
• Complex and high cost claims audits to confirm appropriateness of billing
• Medical Necessity Evaluation
• Prepare files for litigation/Evidence gathering
• Site visits evaluation/ Provider Interview/ Education
• Case coordination with SIU/ OIG/ DOJ
• Recoupment assist

Data Analytics Validation:

• Validate data analytics to ensure that data is clean and correct to take SIU actions
• Point out areas of vulnerability
• Obtain evidence to recoup or prosecute

Fraud Scheme Detection:

• Trend in care management fraud scheme
• Professional and licensing analysis. Identify licensing issues
• Business network analysis to detect organized fraud

Education and Training

• Provide trainining for the SIU team, providers, claim management staff, patients in appropriate topics
• Provide training in clinical documentation
• Provide education for provider compliance with rules
• Provide training and education in compliance

Customer Service
Call:  (562)-945-7224

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

“HCRG’s Utilization Review Service is approved to operate by the California Department of Industrial Relations”