A New Era of Detection
and Program Support
Our Services
Medical Review
Medical necessity review is performed by a highly skilled SafeGuard Services' (SGS) clinician who considers rules and policies as well as standard medical practices in evaluating the services performed and claim billed. This type of review is a thorough examination of a provider's billing practices and may result in education or an overpayment determination. Fraud-level review, also performed by skilled clinicians, is less focused on necessity with the objective of determining if the services were payable as billed or occurrences of potential fraud, waste or abuse. In these situations, it may be determined that services were not rendered or the claim may be denied for technical reasons.
Data Analysis
SGS data analysts and statisticians apply a wide range of detection capabilities, including predictive modeling and complex data mining. Our data analysts apply the business intelligence tools best suited to the need, including various SAS statistical analysis tools, more traditional ad-hoc query tools, geographic mapping, and other tools.
Prevention
SGS applies over 24 years of experience in Fraud Waste and Abuse (FWA) to promote loss prevention by recommending enhancements to payment systems, to proactively pay claims correctly, and minimize future overpayments. SGS systems, clinical staff, and detection applications work diligently to protect your program with leading edge analytics, and the knowledge that only those serving on the front lines of fraud can provide.
Investigations
SGS Investigators substantiate the allegations by analyzing associated records. Desk-level investigations include analyzing information about a subject such as enrollment, claims, and other background data. Field work may include physical address verification interviews with beneficiaries, participating physicians and their staff, and others.
Support for Civil and Criminal Prosecution
SGS applies extensive experience with law enforcement to effectively prepare cases for civil and criminal prosecution, including having SGS analysts and investigators provide testimony, when appropriate.
Overpayment Calculation and Recovery
To identify occurrences of errors, including overpayments, SGS analyzes a statistically representative sample of payments, and then projects findings to the universe as appropriate, resulting in recommended recovery.
Effective and Secure Processes with High Quality Outcomes
When you work with SGS, you work with a team that is:
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Effective – SGS effectiveness has allowed the organization to grow to become one of the largest contractors addressing fraud, waste and abuse for Centers for Medicare & Medicaid Services (CMS).
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Secure – The data being analyzed is secured based on the National Institutes of Standards and Technology (NIST) 800-53 security controls to allow SGS to conform to requirements for federal systems, auditable under the Federal Information Security Management Act (FISMA).