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Clinical Claim Review

Avoid errors and prevent inappropriate payments.

Pre=pay Clinical Claim Review
Use medical records to identify improper billing and prevent paying for erroneous claims with an HMS Clinical Claim Review – both on a pre-pay and a post-pay basis.

Our proven algorithms request medical records only for claims that seem likely to include improper payments based on analysis of our comprehensive dataset. Our statisticians update their models daily to ensure continuous improvement. Then our staff of more than 770 clinicians and certified coders review the selected records to find and prevent inappropriate payments.

The inpatient issues we address include:

  • Diagnosis Related Group (DRG) coding
  • Medical necessity
  • Reimbursement methodology
  • Covered vs. non-covered services
  • Readmissions
  • Level of care
  • Skilled Nursing Facility (SNF) services
  • Inpatient rehab

The outpatient issues we cover include:

  • Observation care
  • Hospice care
  • Home health
  • Lab testing

HMS’s deep clinical experience and unmatched resources allow us to perform high-quality medical reviews, helping avoid regulatory red tape and provider pushback. These reviews are executed within prompt-pay guidelines, and with tools purpose-built for the task.

Best of all, since our accuracy rate consistently exceeds the Centers for Medicare and Medicaid Services’ requirements, we will protect your bottom line with results among the best in the business.

Along with , Fraud Solutions, and Prior Authorizations, Clinical Claim Review is part of your complete solution for fraud, waste, and abuse.

Fill out the contact form today and ensure all of your payments are valid payments with a Clinical Claim Review.