A fraud-and-abuse investigation program for payers, PBMs and healthcare program-integrity units.
This program runs your healthcare fraud, waste and abuse investigation operation across claims, providers and prescription flows. Every matter is resolved end to end, into an enforcement-grade case file. Configured to your benefit design, your program rules and your referral channels. Your Special Investigations Unit or Program Integrity lead stays accountable.
What we investigate
- Provider-billing fraud investigations: upcoding, unbundling, phantom-service and medically-unnecessary-care patterns.
- Pharmacy and prescriber investigations: pill-mill, kickback and DME-fraud schemes. Prescription, claim and referral pattern analysis.
- Member and beneficiary fraud investigations: identity misuse, eligibility fraud and collusion with providers.
- Enforcement-grade case files structured for SIU referral, OIG, DOJ False Claims Act and state Medicaid Fraud Control Unit review.
What’s special
One case file is structured to meet OIG, DOJ False Claims Act and state Medicaid Fraud Control Unit referral standards.