Fraud, waste, and abuse manuals and SIU structure
An SIU file a stranger could follow: intake, the rule, the evidence, and the close.
ReadHealth Plans & TPAs
Fraud, waste, and abuse programs, audits, and claims operations for plans and administrators.
Plans and TPAs have to pay clean claims and still catch the ones that are not. That tension lives in edits, SIU files, and provider education. The firm advises on the program, not only on a single dispute.
Reviewed by Joseph Rivet · September 29, 2026
The Challenge
SIU work that can be shown
A useful SIU file shows intake, the rule applied, the evidence, and the outcome. If the file is only a spreadsheet of tips, it will not travel well in a government review.
Reimbursement, pricing, and billing
How a clean claim gets paid, and how a pricing rule is written down.
Learn moreMedicare, Medicaid, RADV, and commercial audits
Government and commercial reviews, including how a sample becomes a larger number.
ReadClaims edits, analytics, and policy review
An edit that denies a code, tied to a written policy a provider can look up.
ReadAppeals determinations and provider education
A determination letter that cites the rule and the missing documentation.
Read
Who We Help
Who this work is for
The same operational background that serves providers also serves plans: how an edit fires, how a medical-necessity denial reads to a clinician, and how an SIU file looks if it is later produced.
- Medicare Advantage and Medicaid plans building FWA programs
- TPAs that need an SIU manual the staff will use
- Plans answering RADV or other government audits
- Networks rewriting provider education after a spike in appeals
Our Process
First steps you can take today
These steps organize the file. They are not a substitute for counsel.
- 1
Pull five closed SIU files and see whether a stranger could follow the decision.
- 2
List the top denial edits and the written policy each one implements.
- 3
Check whether appeal letters cite a source a provider can look up.
- 4
Note any RADV or government request that is open and who owns it.
SIU work that can be shown
A useful SIU file shows intake, the rule applied, the evidence, and the outcome. If the file is only a spreadsheet of tips, it will not travel well in a government review.
Edits should map to a written policy. An undocumented edit that always denies a code is a claims operation, not a FWA control—and providers will treat it that way on appeal.
Appeals as education
Determination letters that cite the rule and the missing documentation reduce the next wave of the same appeal. That is slower on day one and faster by month three.
When a provider pattern is real, the plan still needs a process that would look fair if it were produced. Speed without a record is a later problem.
Common questions
- Can a TPA rely on the plan’s FWA program?
- Only to the extent the contract says so and the TPA can still show its own controls. Delegated work is still the TPA’s work when a reviewer asks.
- What does a thin SIU file usually miss?
- The rule that was applied, the evidence that was not relied on, and a clear close. Those three items are what later reviewers look for.
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SIU readiness
7 itemsCould this file leave the building tomorrow?
Use one recent matter. If you cannot check an item, the file is not ready for a government request.
Check items off as you collect them. Your progress is saved on this device.
This sheet is a gather list for your own file. It is not legal advice.
When you want help
Bring the letter, the remittance, or the agreement.
If the first steps on this page raised a question, the firm can sit with the file.
This page is educational. It is not legal advice and does not create an attorney-client relationship. Facts, contracts, and appeal windows control the next step.