Resources
Guides for healthcare payment integrity teams
Practical, cited guides for health plan payment integrity, SIU, and Medicaid program integrity teams. They cover how to detect fraud, waste, and abuse, investigate it, and recover from it.
Guides
Payment integrity
Prepay vs postpay FWA detection: where each rule belongs
Which FWA rules work before payment, which need paid-claim history, and how to move rules between stages, with five questions to decide, metrics for each stage, and the Medicare Advantage and Medicaid managed care rules behind them.
Read the guide →Sampling and extrapolation
SVRS for overpayment estimates: a practical guide
How SIU and payment integrity teams build the frame, size and draw a seeded sample, project overpayments with Mean Per Unit and the 90% lower bound, and keep the work papers that hold up on appeal.
Read the guide →Solutions by team
Health plans
Prepay and postpay detection, SIU case management, and medical review for commercial and Medicare Advantage payment integrity teams.
Payment integrity for health plans →State Medicaid and government
Detection, investigations, medical review, and statistically valid sampling for program integrity units, MFCUs, and PI contractors.
Medicaid program integrity →Special investigations units
One case record from first lead to final recovery, with records requests, review, sampling, and a full audit trail.
SIU case management →Tools and references
- SVRS: statistically valid random sampling. Sample sizing, seeded selection, and Mean Per Unit extrapolation.
- Insights. Program integrity dashboards and reporting.
- Security and HIPAA. How we protect PHI.