Wherever reimbursements happen, we are there to serve

Whom we partner with

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

$2 - $3M
average verified annual over-payments per 100K members.
$3M PMPM
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

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

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

COR

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

The secret behind our unmatched savings is no secret

  • IntelliSelect Algorithms
  • Provider Collaboration
  • Data Automation and Implementation
  • Clinical Expertise
  • Compliance
  • Flexibility and Customization
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