Private Insurance Audit Defense Attorney | Insurance SIU Investigation Lawyer

What Is an Insurance SIU Investigation?

SIU stands for Special Investigation Unit. Nearly all commercial health insurance companies have SIUs that investigate suspected fraud, waste, or abuse. 

Insurance companies use SIUs to:

• Investigate suspicious billing patterns
• Review provider documentation for medical necessity
• Identify potential fraud or abuse
• Demand recoupment of alleged overpayments
• Place providers on corrective action plans

If audited by an SIU, you could face delays in payment from the insurance company, recoupment of previous payments, a corrective action plan, and even removal from the insurance plan.

The most severe action an SIU can take against you is to report you to law enforcement agencies like the Office of Inspector General (OIG) or the U.S. Department of Justice (DOJ).

Rarely, an SIU audit can lead to criminal charges. Frequently, it can jeopardize your practice.

SIU investigations often begin with records requests and can escalate to a notice of audit findings, overpayment demands, or recoupments. Sometimes, a records request will be your only warning that an SIU investigation is already underway.

What Should I Do If I Receive a Records Request or Audit Notice?

If you receive a request for medical records from an insurance company, audit notice, or SIU investigation letter, time is critical. Most audit notices provide strict response deadlines – typically 30 to 45 days – and missing these deadlines can result in automatic denials or default recoupment demands.

An experienced insurance overpayment attorney can intervene immediately to protect your appeal rights and challenge improper audit procedures.

Immediate Actions (First 24-48 Hours):

1. Contact an attorney immediately (within 24 hours of receiving notice). An insurance recoupment defense attorney can intervene to ensure the investigation adheres to plan documents and your rights are preserved. Early attorney involvement significantly improves outcomes.
2. Note all deadlines in the audit letter. Mark your calendar with response deadlines, appeal deadlines, and any other time-sensitive requirements. Missing deadlines eliminates your appeal rights.
3. Identify which department is requesting records. If the request comes from the SIU (Special Investigation Unit), this indicates a fraud investigation – not a routine audit. This requires immediate legal counsel.
4. Preserve all documentation. Do not alter, destroy, or "supplement" any records. Document the exact state of all files when you received the audit notice.
5. Document all communications to and from the insurance company. Create a tracking spreadsheet noting dates, methods of contact, who you spoke with, and what was discussed.
6. Do NOT provide statements or sign non-disclosure or confidentiality agreements without legal counsel.

What NOT to Do:

• Do NOT ignore the request – this guarantees adverse action
• Do NOT sign anything – auditors may be seeking to alter the terms of your provider agreement
• Do NOT provide more information than requested – stay within the audit scope
• Do NOT make verbal statements to investigators without counsel present
• Do NOT alter medical records – this can lead to fraud allegations
• Do NOT assume the audit will resolve itself – SIU investigations escalate quickly

Commercial Insurance Audit Defense and Private Payor Overpayment Appeals

Our private insurance audit defense attorneys provide comprehensive representation starting with the initial record requests through overpayment demands or recoupments. Our goal isn't just minimizing what you pay back – it’s recovering what insurers shouldn't have withheld in the first place. 

Many providers facing recoupment demands have legitimate defenses that result in reduced or eliminated overpayment determinations, and in some cases, recovery of additional amounts wrongfully withheld.

Our Audit Response Services:

Our team can step in immediately to:

• Review your provider agreement to understand your contractual audit rights, appeal procedures, and limitations on the insurer's audit scope
• Identify the audit scope (specific services, time periods, patients, and allegations) 
• Assess statute of limitations issues (many contracts limit how far back audits can reach) 
• Coordinate timely, HIPAA-compliant response to medical records requests
• Maintain detailed tracking of all document submissions and communications with auditors
• Coordinate with compliance staff and billing consultants when needed
• Request extensions if needed (often available if requested promptly)

Appeal and Dispute Resolution

• Challenge audit findings through detailed rebuttal with supporting medical necessity documentation
• Engage expert medical opinions to support clinical decision-making and standard of care
• Contest incorrect coding determinations and policy misapplications
• Challenge statistical sampling methodology and extrapolation errors in overpayment calculations
• Negotiate directly with insurance company auditors and medical directors
• Pursue formal appeals through contract dispute resolution procedures
• Litigate in federal or state court when necessary to protect your interests

Insurance Overpayment and Recoupment Defense Services

• Conduct claim-by-claim review of recoupment demands to identify insurer errors
• Assert statute of limitations defenses when audits exceed contractual or statutory timeframes
• Challenge whether the sample claims were truly random, adequately sized, and representative of the claim population 
• Demand full disclosure of the extrapolation methodology – including statistical formulas, confidence intervals, and precision calculations – that led to the overpayment calculation
• Assert contractual limitations contained within the provider agreement 
• Negotiate reduced overpayment amounts through detailed documentation and policy analysis
• Establish payment plans that avoid cash flow disruption to your practice
• Document financial hardship to support reduced settlement amounts
• Coordinate defense against referrals to state insurance fraud bureaus or licensing boards
• Defend Department of Labor (ERISA) investigations when employer-sponsored plans are involved

Many providers don't realize they can challenge not just the audit findings, but also the insurer's method of collecting alleged overpayments. When insurers withhold payment on legitimate claims to offset disputed audit findings, you have legal recourse to demand release of those funds while the audit dispute proceeds through appeals.