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.

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

Forensic Investigation & SIU Support

Advanced Case Support & Technical Expertise

Forensic Accounting Perspective

INSIGHTS & INTELLIGENCE

Bone Growth & Neuromuscular Stimulation for Soft Tissue Injuries,

Or $5,000 Bone-Growth Devices Prescribed for Sprains and Strains

The DME Twilight Zone,

Or when shell companies, suspicious prescriptions, and bilateral airplane braces fly on the same claim

Wheelchair Cushions for Ambulatory Patients

Or When Walking Patients Require Wheelchair-Exclusive Equipment

Who’s Paying for the Lambo,

Or When a Routine Spinal Injection Claim Looks More Like an Invoice for a Luxury Vehicle

Dissecting DME Invoices: How Questionable Invoices Can Turn into an SIU Field Trip

Manipulation Under Anesthesia (MUA) without the Anesthesia

Or When “Creative Coding” Deserves Its Own Award Category

Industry Expertise & 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.

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

Forensic Accounting Perspective

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