Our Pledge of Excellence
Integritas Solutions will deliver the highest quality results for our customers through robust investigations, superior SIU management and oversight. By engaging in a team based collaborative approach for each investigation, we will ensure the outcome exceeds our customers’ expectations. We accomplish this objective by conducting detailed, thorough and impartial investigations that withstand regulatory and law enforcement scrutiny and yield the largest monetary recoupment for our customers.
Achieving your objectives begins with a strategic purpose that is driven by a customized plan. We are guided by results, deliverables and recoveries.
Anatomy of AN investigation
1. Detection and Triage
- Generate and locate leads to substantiate alleged fraud.
- Perform a detailed analysis of payment history.
- Identify suspicious behavior and recommend a course of action.
- Follow matters through to disposition.
- Make recommendations on which matters represent the most significant opportunities for recovery and/or pursuit to regulatory and law enforcement authorities.
2. Investigation & Record Review
- Identify, review and investigate allegations.
- Gather substantive evidence via data analysis and statistical sampling review of medical records.
- Conduct clinical investigation, review for coding accuracy, proper documentation and precise assignment of CPT and HCPCS codes.
- Interviews of members, witnesses and providers.
- Prepare thorough review summary that withstands legal and regulatory scrutiny. If necessary, these findings can be used in a court setting.
3. Recovery & Recoupment
- Report identifying results of investigation.
- Incorporate extrapolation tools, if applicable.
- Work with your organization to assist in the recovery of overpayments or inappropriate payments to the provider.
4. Referrals
- SIU investigative staff comprised of professionals that have worked in all levels of law enforcement and maintain a network of contacts and colleagues that will ensure an impartial review of the findings.
- Review matter for compliance with all State and Federal requirements.
- If warranted, refer the case for prosecutorial action, and/or regulatory sanction which may result in restitution