The Silent Drain on Health Plans
The erosion of healthcare funds through improper claims is a multi-billion-dollar challenge facing America’s workforce. Self-insured healthcare plans, especially those within the port and maritime industries, face unique risks due to their comprehensive benefit structures. While these issues are often invisible to traditional monitoring, the cumulative data highlights a clear need for proactive measures to secure plan assets.
The Scale of the Problem
High-value benefit designs, characterized by zero-copay and zero-deductible structures, can present unique administrative challenges that are often identified by entities seeking to access plan resources. By navigating specific oversight gaps, these entities utilize patterns such as unsubstantiated billing and the unauthorized use of member credentials to divert funds intended for maritime families. These activities are not limited to local port networks but often extend across state lines and even across the world. As demonstrated by the Department of Justice’s “Operation Never Say Die” in April 2026, the methods used to access these funds are continually evolving. This shift highlights that traditional, reactive oversight may no longer be sufficient to protect a plan’s long-term sustainability.
The question isn’t whether your plan is being targeted. It’s how much you’re losing, and whether you have the tools to see it.
The Forensic Strike™ Methodology
MHMDAA was built to give health plans the forensic intelligence needed to detect, document, and eliminate healthcare fraud before it drains another dollar. We combine physician-level clinical expertise, attorney-grade legal rigor, and AI-powered data analytics.
A 3-Year Subscription to Continuous Protection
The Forensic Strike™ engagement is not a one-time audit—it is a structured, three-year subscription commitment designed to deliver compounding protection. The first phase begins with a deep-dive forensic audit to establish your plan’s baseline, identify existing vulnerabilities, and surface active fraud patterns. From there, MHMDAA transitions into an ongoing monitoring and enforcement posture, continuously adapting to new fraud schemes as they emerge. Each year builds on the last, deepening our forensic intelligence of your plan, your providers, and your claims environment—so that the longer we work together, the more fraud we catch, and the more your plan saves.
Intelligence Gathering
We begin by ingesting your claims history, provider network, and plan design, mapping the landscape before a single algorithm is applied.
Digital Dragnet™ Deployment
Our AI-driven engine applies 17 concurrent detection modules spanning billing behavior, network relationships, spatial clustering, temporal validity, and NLP-based documentation analysis.
Clinical Forensic Review
Every algorithmic flag is reviewed by physician-led clinical teams, ensuring true anomalies are distinguished from false positives through real-world clinical judgment to isolate genuine fraud from statistical noise.
Audit-Proof Evidence Packaging
We document confirmed fraud to prosecution-ready standards, enabling seamless referral to DOL-OIG, DOJ Healthcare Fraud Strike Force, and DOL-EBSA.
Ongoing Subscription & Continuous Protection
A 3-year engagement beginning with a deep-dive audit to identify client-specific needs. From there, we determine plan design adjustments, deploy the Digital Dragnet™, and transition into continuous monitoring, overpayment recovery, and escalation coordination as a standing service.
The Digital Dragnet™ Analytics Engine
At the core of every Forensic Strike engagement is The Digital Dragnet™, our AI-driven analytics engine purpose-built to detect complex fraud schemes in health plans. Seventeen detection modules run in parallel, designed to identify coordinated fraud patterns.
Statistical Outlier Detection
Applies Z-score analysis and Benford's Law to surface fabricated billing amounts and extreme deviations from peer norms.
Batch Billing Detection
Leverages Shannon entropy analysis to identify fraud mills billing the same limited set of codes across nearly every patient.
Cookie-Cutter Documentation
Uses clinical NLP models to identify semantically identical SOAP notes across patients, indicative of templated or fabricated records.
Network and Travel Pattern Analytics
Analyzes provider networks, service locations, and timing to identify suspicious patterns, including unrealistic travel, coordinated billing activity, and hidden relationships indicative of organized fraud.
Credential Laundering Detection
Continuously monitors identifiers to detect terminated or excluded providers billing under borrowed identities.
High-Dollar Claim Review
Physician-led line-item review of high-dollar claims prior to payment. Each claim is evaluated for medical necessity, coding accuracy, and consistency with the member's clinical record, flagging inflated or unsupported charges before a single dollar leaves the trust fund.
What Sets Us Apart
The healthcare fraud consulting landscape is crowded. Our model combines investigative rigor, clinical insight, and sophisticated data analytics purpose-built for the unique challenges of health plan fraud.
Physician Leadership
Every audit is grounded in both clinical medicine and legal strategy, ensuring we understand clinical realities and package findings to federal evidentiary standards.
Specialized Health Plan Expertise
Focused on self-insured health plans, with expertise in their structure, regulatory frameworks, and patterns of potential misuse.
AI-Powered, Clinician-Validated
Our machine learning models are validated by our physician-led team, ensuring only genuine fraud proceeds to investigation.
Global Talent, Local Accountability
Our U.S.-based leadership oversees a 24/7 globally distributed analytics team operating across every time zone, delivering round-the-clock monitoring, faster investigation turnaround, and significantly lower cost than traditional domestic-only engagements. Continuous operations mean no gaps, no delays, and no missed fraud signals.
The Most Formidable Shield for Your Plan Is Proactive Prevention
The enforcement environment has never been more active, with federal prosecutors securing longer sentences and recovering larger sums. However, enforcement is reactive; by the time a case reaches prosecution, millions have already been lost.
Your plan’s most valuable defense is prevention: identifying fraud at the point of claim submission, before a single dollar leaves the trust fund.
If your plan pays claims without forensic oversight, you are losing money to fraud. The only question is how much.
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