DRG
The largest liabilities occur here and our team works meticulously to locate the claims that are likely to yield the greatest recoveries. With respect for the burden on providers, we work amicably to minimize friction and maximize savings.
Our record speaks for itself
average verified annual over-payments per 100K members.
in additional annual savings, surpassing industry standards.
Selection
Our two-tier selection analysis yields higher audit potential and savings. Claims data is run through our proprietary algorithms, and claims that fall out proceed to our “hands on” selection process resulting in a more thorough review with increased payment recovery identifications.
Validation
A thorough review of medical record documentation is performed on claims paid using the MS-DRG or APR-DRG methodology. Documentation, including clinical indicators, must support code assignment, and Official Coding Guidelines must be followed for principal diagnosis selection. Our experienced, credentialed team validates the following:
- Principal diagnosis code assignment
- Secondary diagnosis code assignment
- Discharge Disposition assignment
- Procedure code assignment
Outliers
Our Inpatient Hospital DRG Cost Outlier reviews boast a thorough and extensive analysis of itemized charges that drive the claims into an outlier status for additional payment, as well as review claims that are paid a percentage of billed charges. Line by line of the itemized bill is reviewed to ensure each charge is appropriate.
The factors include:
- Duplicate and unbundled
charges for inclusive services - Up-coded charges
- Length of stay
- Overstated bed charges for level of care provided
Short Stay
Our specialized team of clinical professionals is committed to providing comprehensive auditing services for both post-payment and prepayment scenarios. Observation claims play a significant role in hospital revenue cycles and healthcare billing, ensuring that appropriate care is provided to patients while maintaining compliance with insurance regulations and guidelines.
We conduct thorough Short Stay Claims audits, focusing on a designated lookback period. Additionally, we perform prepayment audits for current 1-2 day stay claims, targeting claims for appropriate hospital admissions. With a keen eye for detail, our clinical auditors meticulously validate and determine whether these claims are best processed as Observation Stays or categorized as Medically Necessary Admissions to healthcare institutions.
Our commitment to precision and expertise ensures that the billing and categorization of Short Stay Claims align seamlessly with the highest standards in healthcare management.
The Result
We regularly produce >50% findings for overpayment
Readmission
Our audit team reviews claims for patients who are readmitted to the provider’s facility shortly after being discharged for the same or a related condition. Efforts to minimize healthcare billing for unnecessary readmissions are central to our mission.
Our comprehensive approach includes:
- Detailed document review substantiating the readmission's necessity
- Ensuring readmission policy compliance
- Coordinating with payer to facilitate smooth claim processing for identified recoveries
APC
As a growing component of the claims management arena, the auditing of Outpatient Services is another area we have become a leading aid to insurers. We are best known for achieving successful and timely audit results.
A comprehensive review of all documentation is performed validating accurate HCPCS/CPT code selection. Medical record documentation must support facility E/M code. Orders and results must coincide. Infusion and injection codes must be accurately distinguished by capturing correct units.
Experienced, credentialed team seeks to validate the following:
- Diagnosis code (ICD-10-CM)
- Procedure code (CPT/HCPCS)
- E/M
- Infusion/injection codes (as applicable)
- Units billed
- Modifier(s) appended performed on outpatient records selected based on review type
SNF
RUGS or PDPM calculations drive reimbursements to our partners in the nursing home industry. Our innovative systems and skilled team ensure that plans receive the full-service auditing they are entitled to — and more.
Our team undertakes an in-depth review of medical record documentation to ensure accurate RUGS or calculation is assigned in compliance with all regulatory requirements. MDS and orders must correspond with documentation of services provided. We provide experienced RN validation of documentation supporting the five case-mix adjusted components of Patient-Driven Payment Model (PDPM)
- Physical Therapy (PT)
- Occupational Therapy (OT)
- Speech-Language Pathology (SLP)
- Non-Therapy Ancillary (NTA)
- Nursing
The Result
We regularly produce 20-25% findings for overpayment
The secret behind our unmatched savings is no secret
- IntelliSelect Algorithms
- Provider Collaboration
- Data Automation and Implementation
- Clinical Expertise
- Compliance
- Flexibility and Customization