OVERVIEW OF AUDIT CYCLE:

100% of a client’s DRG claims are transmitted and screened through our proprietary “rules engine,” identifying an average 30% with the greatest potential for audit results.

  • Post Payment:  For those selected claims, Medical Records are then obtained from the hospitals and each one is thoroughly analyzed by our professional coding and auditing experts.
  •  Pre-Payment:  Claim selection for audit is completed within one business day. Clean claims are advanced back to the health plan for regular claim processing.  Unclean claims will be identified so that claims advice and a request for additional clinical information is generated by the health plan.

When errors are identified in the medical record documentation, the providers’ coding departments receive our detailed recommended changes and rationale based on official coding guidelines and resources.

  • Pre-payment:
    • Health plan pays the recommended DRG within the clean claim timeline.
    • Providers return a signed agreement to our recommended changes enabling us to forward the agreement and the revised pricing detail to our clients to process the credit or refund request.
  • Pre-payment:
    • In the event the provider’s billing is confirmed by additional documentation submitted by the provider, the remaining balance of the originally billed DRG is then paid.
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