Special Investigation Unit (SIU) Services

Vendors to provide post- payment claim review services such as recognizing and flagging member eligibility and provider billing abnormalities indicative of fraud, waste, or abuse; identifying, investigating and recovering overpayments; collaborating with the Agency’s Third Party Administrator (TPA) to implement prepayment reviews of claims submitted by providers identified as outliers to prevent improper payments; and collaborating with the Agency’s Pharmacy Benefit Manager (PBM) to implement post-payment processes to reduce and recover improper payments more effectively and efficiently.
- Vendor will request, obtain, evaluate, and audit medical records, employee files, time sheets and other relevant documents to determine whether providers submitted claims appropriately and/or whether individuals enrolled in PEIA’s plans were eligible for enrollment, using a secure, web-based portal that allows healthcare providers and others to electronically upload digital copies of medical records and
other responsive documents.
- Vendor will evaluate and audit claims on an itemized, line-by-line basis as they were adjudicated or as they should have been adjudicated after reviewing medical records and other relevant documents for coding accuracy, clinical documentation alignment, and compliance with applicable policies and documentation requirements.
- Vendor will plan and conduct sensitive and complex investigations into suspected FWA, including but not limited to record reviews, claims data analysis, interviews, interrogations, evidence collection, surveillance, and database research.