Case Study: Northeast Health Plan Provider achieves $7M+ overpayment recovery and stops provider fraud with SCIO Health Analytics

Northeast Health Plan Provider - Customer Case Study

Northeast Health Plan Provider, a 2.8 million-member health plan, faced rising specialty pharmaceutical claims and suspected systemic improper billing by providers. Lacking the internal analytics resources and specialty‑pharma expertise to identify and recover overpayments or pursue fraud, they engaged SCIO Health Analytics to provide specialized data analytics and investigative support.

SCIO Health Analytics reviewed specialty drug claims across providers and places of service, flagged coding, dosing and vial‑size anomalies, and conducted in‑depth claim reviews, then referred verified patterns to the plan’s SIU. The engagement stopped new claims to problematic providers, identified over $7M in overpayments (including $1.5M avoided to an infusion provider and $2M linked to vial‑size miscoding), led the providers to discontinue inappropriate billing, and produced SIU cases that involved law enforcement.