A healthcare plan audit program
to safeguard your plan assets
is a Best Practice

 

Focused Sample Claim Audits

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Our Focused Sample Audits identify overpaid medical claims.

 

On average, 3% to 5% of all claims involve some type of overpayment. The focused Sample Audit is focused on categories of claims that result in the largest overpayments.

 

The Focused Sample Audit is supported by a general Operational Review.

 

 

To begin the Focused Sample Audit process, we request an electronic claims file from your TPA. This file includes 100% of the claims paid by the TPA for the period requested by our client. We analyze your plan benefits and convert the plan provisions into specific diagnosis and procedure codes. We use our audit specialists and our proprietary software to electronically compare the claim file to your Plan Benefits. In addition, we search for duplicate payments, claims paid for terminated employees, incorrect COB calculations and a number of other types of potential errors. The results of these queries are used to select the on-site audit sample.

 

The following is a partial list of potential overpayments our audits uncover.

  • Were provider network discounts correctly calculated?
  • Was the patient eligible for coverage on the date of service?
  • Were there coordination of benefits or subrogation issues?
  • Did the plan cover the services provided?
  • Were any coverage limitations exceeded?
  • Were there duplicate payments?

 

Each year our recovery audit services obtain millions of dollars in refunds from overpaid claims for plan sponsors. MedReview’s recovery audits have secured individual claim overpayments exceeding $500,000.