SCREENING-2773 - USA (Charleston, West Virginia) - Special Investigation Unit Services - Deadline November 6,2026

(1) Vendor needs to provide special investigation unit services to the government authority located in Charleston, WV.– Provide post– payment claim review services such as recognizing and flagging member eligibility and provider billing abnormalities indicative of fraud, waste, or abuse; identifying, investigating and recovering overpayments; collaborating with the agency’s third party administrator to implement prepayment reviews of claims submitted by providers identified as outliers to prevent improper payments; and collaborating with the agency’s pharmacy benefit manager to implement post–payment processes to reduce and recover improper payments more effectively and efficiently.– Provider billing patterns and behaviour using peer comparison, data mining, rules–based, artificial intelligence (AI) and other analytics.– Vendor will request, obtain, evaluate, and audit medical records, employee files, time sheets and other relevant documents to determine whether providers submitted claims appropriately and/or whether individuals enrolled in plans were eligible for enrolment, using a secure, web–based portal that allows healthcare providers and others to electronically upload digital copies of medical records and other responsive documents.– Vendor will plan and conduct sensitive and complex investigations into suspected, including but not limited to record reviews, claims data analysis, interviews, interrogations, evidence collection, surveillance, and database research.(2) All the questions must be submitted no later than October 9, 2026.