Q: How are you different than other claims editing and fraud, waste   and abuse detection service?

A: First, AMG-SIU does not offer a product, but a service. Other companies provide a hardware or software product and drop it off at a clients’ office.

The client is responsible for maintaining it, learning how to use it and hiring experts to handle it. AMG-SIU provides a service- clients are trained to use the ACE system and work with SIU experts on investigations.

Secondly, AMG-SIU’s service is much more comprehensive than anyone else’s. AMG-SIU’s ACE system edits claims from all provider types on the Federal, State, Payer and Plan levels, including the Medicare and Medicaid programs. The system uses at least 3 years of data in its analysis.

Most other solutions only perform basic federal out-patient edits. That’s why other solutions only capture 1-2 percent savings, but AMG-SIU’s solution captures an average of 10-15 percent.

AMG-SIU also has a full Special Investigation Unit of experts to analyze claims data and medical records and conduct preliminary and extensive investigations. The team of SIU experts, comprised of insurance industry experts, fraud, waste and abuse investigators, health care professionals, legal professionals, certified coders, fraud examiners,  and data analysts, review claims data and medical records and conduct all necessary investigations to the strictest confines of federal and state law.

Q: What type of edits do you provide?

A: AMG-SIU’s ACE system includes more than 120 categories of edits. This results in millions of  detailed elements of customized logic. AMG-SIU’s edits were created by a team of legal, investigations, operations and certified coders from all government regulatory bodies that would be applicable.

For example, the AMG-SIU edits containfederal and state specific logic as well as edits that the operations team created base on decades of experience. Clients have the ability to decide what edits and edit categories are applied to their claims data and work one-on-one with our edit experts to create a customized edit library.

Q: How do you create your edits?

A: AMG-SIU uses a team of legal, investigations, operations and certified coders to research federal, state and government program laws – such as Medicaid and Medicare - and translate them into a code of text. That information is then sent to AMG-SIU’s edit development team of database professionals to translate that text into a computer code that will work in the ACE system.

Once the edit is codified in the ACE system, sample data is run against the edits and the resulting data is analyzed by the team of legal, investigations, operations and certified coders to ensure that the edit is performing accurately. Once an edit is finalized, clients are notified of the change and the client contact discusses whether or not the client wants to include that edit with the edits they have already chosen.

Q: Do your edits include non-standard codes?

A: Yes. AMG-SIU can create custom edits for clients that do not use standard codes, and utilizes many categories of edits to catch instances of fraud, waste and abuse that would not be possible with only government-sourced edits.

Q: Can you integrate your system with my current system?

A: We can try. AMG-SIU aims to pull data from our clients system, process it and integrate it back into the client system. However, each system is different we have found that many clients legacy systems do not have the capability to pull data and integrate our data automatically.

Typically, our clients manually extract data from their system, AMG-SIU processes it, and if needed, cross walks the data to work with the existing clients’ system, and the resulting file is downloaded into the client system, available for viewing.

Q: Who performs your fraud, waste and abuse investigations?

A: A team of investigators, RNs, certified coders and data analysts conduct all preliminary and extensive investigations, including the hardcopy medical record and prescription review. On occasion if the investigation requires a specialty review, the SIU unit will use one of our contracted specialty physicians to review files.

Q: Do you provide monitoring in your SIU?

A: Yes, the SIU can monitor anyone involved in an investigation, if that’s a specific facility, provider, member or anyone else. Monitoring can be conducted for any length of time, dependent on governing regulations and the clients’ needs.

Q: How do you conduct appeals/formal inquiries?

A: All investigations are performed to the strictest levels of federal and state laws, regulations and policies. Reports and findings are documented to be litigation-worthy and are linked to the appropriate federal and state regulations, policies and laws.

Q: What type of reports can I get?

A: AMG-SIU offers access to more than 100 different reports in 9 categories via a HIPAA-compliant web interface. These reports are accessible on-demand to view on the website or for download once data has been processed through the ACE system. These categories include:

Q: How often can I get reports?

A: Reports are available for clients to access once their data has been processed. Data processing typically takes less than 20 minutes once received, but can vary depending on the size of the transmission.

Once processed, clients can access more than 100 reports via AMG-SIU’s HIPAA-compliant web interface and either view or download the reports.