A healthcare plan audit program
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Medicaid / Medicare Audits

MedReview’s Medicaid/Medicare Audits review claims for various overpayments, underpayments and anomalies, but more importantly, they include the review of charges to ensure regulation adherence.

 
The regulations are very clear as to what is required in order for charges to be considered acceptable for billing.

 
Requirements may include supporting documentation for all charges billed, evidence of physician visits and accurate coding.

 
Proper documentation can be found in physician orders, progress notes, operative reports and test results. These documents are gathered and scrutinized to certify that all were correctly billed charges.

 

MedReview also looks for proof of documentation that confirms the degree of medical problems, patient’s history, examination and/or test results, symptoms and complaints.

 

The documentation required needs to include a review of the patient’s medical records to verify that services were medically necessary, and that the services rendered were as billed on the claim.

 

While we always review for appropriate and consistent diagnosis codes (ICD-9-CM) on each claim, we also seek additional information if necessary.

 

For example: when modifier 22 is indicated on a claim, an operative report and a concise statement regarding how the services differ from the usual must be submitted. Our audit ensures that the statement has been obtained and/or obtains the statement necessary for reviewing the charges.

 

MedReview’s Medicaid/Medicare audits are aggressive, they audit based upon a variety of statistical triggers that are built into our proprietary system. This proprietary system, combined with a complete review by our qualified nurse auditors, ensures complete compliance.

 

Reference: (Medicare Policy Manual, DOC-1, “Documentation of Services”, Rev. 3/97.)