Focused Sample Claim Audits
Our Focused Sample Audits identify overpaid medical claims and, if warranted, recovers these overpayments for you.
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. MedReview also recovers overpaid funds for the plan sponsors and supervises the collection of overpaid funds if the plan administrator collects the overcharges.
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 on your behalf over the past eighteen months. Most providers will not agree to overpayments for claims paid prior to eighteen months from the date of the audit. We analyze your plan benefits and convert the plan provisions into specific diagnosis and procedure codes. We use 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. Due to time constraints, most TPAs will not permit on site audits of more than 250 claims.
The following is a partial list of potential overpayment issues our recovery audit services review.
- 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.