SIU & FORENSIC ACCOUNTING
AJHC Financial Partners supports Special Investigation Units (SIU), insurance carriers, legal teams, and government agencies in identifying, analyzing, and resolving complex healthcare billing irregularities, fraud indicators, and high-risk claims.
With a background in healthcare compliance, medical coding, reimbursement methodologies, and forensic accounting, we bring a structured, data-driven approach to claim investigation and financial validation.
Where We Add Unique Value:
- Cases where fraud is suspected but not clearly provable
- Situations involving complex billing structures, EHR systems or specialty services
- High-exposure claims requiring clinical + financial interpretation
- Investigations where documentation, timing, and policy language drive outcomes
Advanced Investigative Approach
With deep expertise in Federal (CFR) and State (i.e. NYCRR, DFS, WCB, DOH and other) regulations, AJHC brings a forensic, system-level perspective to healthcare investigations—recognizing that fraud often emerges at the intersection of policy gaps, operational inefficiencies, and reimbursement structures.
We help SIU teams move beyond surface-level review by:
- Identifying how fraud patterns develop within healthcare systems
- Distinguishing between intentional fraud, operational inefficiencies, and documentation gaps
- Applying regulatory language and timing logic to strengthen investigative conclusions
- Structuring findings to support litigation, arbitration, and recovery efforts
Forensic Investigation & SIU Support
We assist SIU teams in building structured, defensible, and evidence-based cases through:
- Forensic analysis of medical billing and reimbursement patterns, including tracing financial transactions, auditing for “phantom billing,” and identifying shell companies
- Identification of fraud indicators, including:
- Upcoding, unbundling, and duplicate billing
- Misrepresentation of Provider Type / Scope of Practice Violations
- Credentialing / Privileging Violations
- Misrepresentation of Services performed
- Modifier misuse and documentation gaps
- Inconsistent utilization patterns
- Validation of medical records and clinical documentation against billed services
- Analysis of provider behavior across claims and specialties
- Development of clear, defensible investigative findings
Advanced Case Support & Technical Expertise
AJHC brings hands-on experience supporting complex investigations, including:
- Preparation of coding reviews and affidavits for litigation and arbitration
- Analysis of RVU-based anomalies and reimbursement irregularities
- Use of EHR data logic, audit design, and regulatory frameworks to strengthen investigative conclusions
- Development of innovative documentation methodologies to support strong, defensible SIU cases
Industry Engagement & Thought Leadership
AJHC Financial Partners brings extensive experience across No-Fault (PIP) and Workers’ Compensation environments, supporting complex claim reviews, dispute evaluation, and reimbursement validation.
- Supported arbitration and litigation matters, including case reviews for major insurance carriers such as American Transit Insurance Company, National General Insurance Company, Integon Indemnity Corporation, GMAC, Adirondack Insurance Exchange, New South Insurance Company, and Esurance Property and Casualty Insurance Company
- Actively engaged in regulatory and legislative processes by identifying policy and compliance gaps and collaborating with agency committees and industry stakeholders to inform the development, refinement, and evolution of healthcare regulations
- Participated in the development and drafting of healthcare regulations and policy frameworks in collaboration with regulatory agencies and legislative stakeholders
- Served as Subject Matter Expert in various panels as unbiased party for claim reviews and dispute analysis involving medical billing, coding, and payment calculations across No-Fault and Workers’ Compensation matters, supporting outcomes across pre-litigation, arbitration, appeals, and litigation.
- Active member and Chapter Speaker with the Association of Certified Fraud Examiners (ACFE), specializing in healthcare fraud, regulatory compliance, and No-Fault / Workers’ Compensation frameworks
- Member of the New York Alliance Against Insurance Fraud (NYACT), contributing to industry efforts addressing complex PIP / No-Fault fraud schemes
- Conducted regulatory compliance audits for the New York State Department of Health (NYSDOH), including cost reports, supplemental payments, provider reimbursements, and claims adjudication policies
- Performed internal audits for large healthcare systems and medical groups, verifying billing accuracy and compliance with Workers’ Compensation, Medicare, Medicaid, and commercial payer requirements
AJHC actively contributes to advancing investigative approaches in healthcare fraud, with a focus on No-Fault and Workers’ Compensation systems.
Industry Engagement & Thought Leadership
With formal training in a nationally recognized Forensic Accounting program (Montclair State University LEARN MORE >>), AJHC integrates financial analysis with healthcare expertise to:
- Quantify exposure and financial impact
- Identify systemic billing patterns
- Support litigation and recovery efforts
- Translate complex healthcare data into clear financial narratives
