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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.

With HMS, we go to work for you – using the broadest range of forensic edits to review claims for errors and potential abuse. Our pre-pay and post-pay edits conform to federal and state regulations, and are customized to match your own policies.

Guided analytics conducts claim-level analysis of improper billing issues and uses statistical/anomaly pattern analysis to flag potential issues. Through link visualization, HMS’s dashboards and provider scorecards quickly identify, prioritize, and review high-risk providers, members, and services to determine if further action is warranted.

By performing a Clinical Claim Review, many types of errors can be avoided:

Inpatient Claims Review Services including,

  • 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

Selected Outpatient Services including,

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

As part of HMS Improper Payment Prevention, Clinical Claim Review uses proven algorithms allowing us to request medical records only for claims that seem likely to include improper payments based on analysis of our comprehensive data set. 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 prevent inappropriate payments.

Our deep 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. With an accuracy rate that consistently exceeds the Centers for Medicare and Medicaid Services’ requirements, you can be sure that your bottom line is being protected by a partner with results among the best in the industry.

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