Healthcare Fraud, SIU, & Compliance Investigations
IntegrityM helps public and private payers uncover fraud, document findings, and mitigate risk. We partner with federal agencies, state Medicaid programs, and managed care organizations to investigate allegations, detect anomalies, and support program integrity efforts through defensible, evidence-based methodologies.
Our Investigative Expertise
Our team has decades of experience supporting CMS, DOJ, and MCOs. We specialize in:
- Fraud detection & anomaly analysis
- Developing evidence-backed cases for administrative or legal action
- Investigations support and guidance for defensible outcomes
- Subject matter expert testimony for administrative or legal proceedings
- Payment model investigations
What We Investigate
We investigate a wide range of fraud schemes, payment irregularities, and provider behaviors. Combining data analytics with regulatory expertise, we uncover misconduct and drive appropriate action.
- Data-driven anomalies in claims, encounters, and pharmacy
- Provider billing fraud and coding irregularities
- Prepayment/post-payment review triggers
- Allegations from internal or external complaints or leads
- Criminal enterprise associations and network-level provider fraud schemes
How We Support the Government and Health Plans
IntegrityM partners with federal and state agencies and private plans to streamline fraud investigations, enforce compliance, and improve program oversight.
- Advanced analytics for pattern and trend detection
- Alignment with CMS and state level Medicare and Medicaid investigative protocols
- Structured documentation and case summaries
- Program integrity audits and policy compliance reviews
- Support for law enforcement referrals or MFCU coordination
- Final investigative reports with evidence based findings
Special Investigations Unit (SIU) Services
We serve as a full or partial SIU partner, delivering:
- AI-powered fraud detection platforms
- Claims, encounter, and quality audits
- Medical record review and field investigations
- Compliance dashboards and KPI reporting
- Training for payer staff in fraud detection and SIU best practices
Case Development & Administrative Actions
We produce evidence-ready deliverables to support enforcement and oversight actions. Deliverables include:
- Investigative summaries
- Chronologies and evidence packets
- Identification of compliance gaps and corrective action plans
- Case support for administrative actions such as sanctions, payment suspensions, or civil enforcement proceedings
Schedule a Consultation
Explore how IntegrityM can strengthen your fraud investigations or build a scalable SIU solution.
