Healthcare Auditing

Our experienced Investigation and Audit teams take a comprehensive approach to each and every provider audit we perform. We believe a thorough analysis of healthcare claims and services enable us to find and evaluate fraudulent patterns of behavior present in the cases we investigate. We are committed to working with government agencies and payers to identify, resolve and prevent future fraudulent medical activity.

Healthcare Fraud Investigations performs Healthcare Audits in accordance with governing Federal, State, and applicable Health Plan guidelines. Our audits provide detailed insight into the organizational performance and compliance of healthcare providers. Through our assessments we are able to make recommendations to improve and better outcomes.

Healthcare Reviews & Audits We Perform

Our auditing department has clinical, billing, coding and investigation experience to research and analyze the unique situations each case presents. By combining our healthcare industry knowledge, advanced technology, and tools, we are able to deliver cutting edge results fast and consistently. Areas we extensively cover when auditing providers include:

• Inappropriate Billing: We check to ensure all services that are billed are properly documented and have verifiable medical necessity associated with them. We also discern if there is unbundling, billing for services never provided or recorded, over-billing for procedures, and false claims.

• Misdiagnosis of Patients: Unfortunately misdiagnosis of patient illnesses can lead to life threatening conditions or situations where patients are unnecessarily exposed to needless procedures with the risk of danger. Given the evidence we receive, we evaluate if the services are misdiagnosed due to error or if there is a pattern of consistent misdiagnosis for the purpose of billing the payer.

• Over Utilization of Provider Services: A common pattern of fraudulent behavior across all forms of healthcare is the recurrence of services being over utilized. In most cases this is to increase the billed amount, or due to improper understanding of medical guidelines for the service to be rendered.

• Practicing Medicine Illegally: We provide verification for all applicable State and Federal licenses, certifications, and qualifications of Physicians, Nurses, Technicians and medical staff present in the cases we review.

Healthcare Auditing is not easy. It can be complicated and require countless hours of research and investigation. Healthcare Fraud Investigations provides a team with a wealth of experience, knowledge, and tools specifically designed to effectively ensure proper auditing of healthcare providers. Our team is eager to help payers and providers in clearing the healthcare system of errors and improper practices. We are here to help. We have the skills, the tools, and the ethics to make the American healthcare system an ideal one.