AMG-SIU provides an array of health care claims editing services and fraud and abuse services. These services are offered separately or in combination according to your specific needs (See Program Options). While a few services must be combined, the remaining services are optional and may be provided by your existing staff (or ours) .

When necessary, AMG-SIU will request records from an investigated provider as well as supporting providers to verify continuity in information for service procedures and the quality of care. Medical records will be requested from the provider for the number of patient records and number of years as required by the health plan and the law. If necessary for a complete and accurate audit, AMG-SIU may request and review other records as needed.

• Medical Records Review – Non-Medical: Determine if claims submitted for payment by the provider are consistent to the patient’s medical file.
• Medical Records Review – Medical Director, Physician, or Professional: Determine if the provider provided the appropriate level of services, tests, and procedures for the health and well-being of the member.
• Pharmacy Review: Identify specific known areas of fraud and abuse. The prescription drug information (NDC record) will be used to analyze the physician’s prescribing patterns, the member’s utilization, whether the prescriptions are appropriate and medically necessary for the member, and no abuse is taking place.