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) .

The retrospective claims payment review allows health plans to identify any claim errors, inconsistencies, fraud, waste or abuse for claims after the claim was paid.

The retrospective review includes:

• Claims paid, denied, or closed by the health plan where the claim was previously processed through the pre-payment claims editor.
• Claims paid that were not processed through the pre-payment claims editor for possible recovery.
• Claims from capped carve-out entities to edit for accuracy and an objective analysis of the services provided.
• Claims from fee-for-service carve-out entities to determine any adjustments to be made prior to payment.

Please refer to the Pre-payment Automated Claims Evaluator (prospective review of claims) section for a more detailed description of our AMG-SIU Automated Claims Evaluator (ACE).