Trained professionals perform a review of outpatient claims designed to identify and assess areas of vulnerability related to reimbursement and compliance. Some examples of areas reviewed are:
Medical necessity, e.g. rejections
HCPCS/CPT code assignment
HCPCS/CPT codes and revenue code linkage
Modifier application
Units of Service
Value and condition codes
"Date spans"
Non-covered codes
Billing manipulations
Edit validity
Bill type
Additional features:
Review and investigate "medical necessity issues" directly related to an actual documented physician's order versus ICD-9 diagnosis codes submitted.
Review and investigate "billing" edit capabilities to compare final UB04 against UB04 received by third party.
Identify issues related to the CDM, e.g. hard coded versus dynamic coding assignments.
The primary benefits are to identify reimbursment opportunities, augment on-going compliance processes and establish a foundation for operational improvements.
