SIU Services

Insurance companies today face the challenge of protecting their network against fraud, waste, and abuse while not adversely impacting their Medical Loss Ratio (MLR). Moreover, Special Investigation Units (SIU) face reduced budgets and increasingly strained resources. Fully outsourcing or partially outsourcing components of SIU responsibilities serve as a solution to the budgetary constraints. Healthcare Fraud Shield provides Subject Matter Experts trained to:

  • Analyze claims data and develop sustainable cases
  • Detect systemic weaknesses
  • Investigate cases
  • Prevent fraud using edit or policy recommendations, provider/member education and more

An integrated fraud, waste, and abuse solution that utilizes unique and proprietary data sources to maximize Return on Investment (ROI) and achieve superior results.

A pre-payment solution to reduce dollars lost from payment of ineligible claims.

A post-payment solution to monitor claims and suspicious activities.

A pharmacy analytics solution to identify improperly billed prescription drugs.

An AI-driven anomaly detection platform that identifies risk vectors from emerging schemes and behaviors.

An ad-hoc tool to run real-time queries and complex pattern reports from loaded data.

Expert analysis of claims, development of cases, and detection of systemic weaknesses.