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) .

(Prospective review of claims)

AMG-SIU’s pre-payment automated claims evaluator (ACE) compares incoming claims to prior claims history, compiles a meaningful analysis, and identifies incorrect billings and questionable claims based on a wide array of edits and data pattern analysis. The SIU system evaluates the codes submitted based on the relationships between thousands of surgical, medical, radiology, laboratory, and pathology procedures and services.

Claims edits and rules within the SIU system are programmed to identify and create adjustments for inconsistencies and billing errors. The SIU system is anti-fraud software designed with the ability to use layered logic, artificial intelligence, and business intelligence algorithms to consistently and accurately execute its functions. Inappropriate coding and discrepancies are documented within the SIU system.

The SIU system uses an enhanced adjudication engine, to review coded claims data and identify treatment codes that are improperly coded or clinically inconsistent. Each claim is screened against the user-defined database which contains:

• Federal and State guidelines
• Medicare and commercial payment guidelines
• Provider contract terms (division of financial responsibility benefit categories)
• Place of service
• Type of service
• Code-specific logical relationships related to medical, surgical, and diagnostic procedures identified by various coding systems.

Using nationally recognized policies and standards the SIU system detects fraudulent and abusive billing practices. This creates the reporting necessary to fully document the provider’s billing practice and substantiates the appropriateness of the detected activity.

Reports are available on-line immediately upon completion of system editing. These reports are presented in a comprehensive format detailing the claim and contra-claim in question. The reports can also be downloaded to a PDF, Word, Excel or rich text document. The Excel file can be used for uploading the data into your claims system for edit adjustments. If the file is too large to export to Excel, AMG-SIU will create an uploadable file and place it on our secure FTP site for your retrieval.

We encourage health plans to utilize the prospective claims audit option to ensure accuracy of claims payment BEFORE the check is issued. Not only does this help in training claims processors to identify potential abuse, it also saves the health plan time and money by reducing the need of after-payment recovery.