What is Clinical Claim Review?
Clinical Claim Review is the process of comparing medical claims against medical records to assure that services documented are accurately coded and billed in the medical claim. HMS’ staff of highly experienced clinicians and coders perform these medical record reviews to verify proper coding, level of service and other reimbursement errors on both a pre-pay and a post-pay basis. Some of the issues appropriate for clinical claim review include diagnosis related group (DRG) coding and validation, as well as readmission and level of care reviews. HMS uses innovative, machine-learning driven algorithms to identify and select claims with the highest potential for payment inaccuracy. HMS algorithms are developed and continuously updated using our large claims data sets and vast experience in healthcare data analytics.
Preventing improper and inaccurate medical claim payments
HMS uses time-tested algorithms to target claims with the highest potential for findings—requesting medical records only when there is a likely improper payment.
Our statisticians update their models daily to ensure continuous improvement. Once the medical records are received, our highly experienced, expert clinical and coding team review the selected records to identify inappropriate payments. The team completes the clinical claim review within timelines that allow processing of the claim within the prompt pay requirements.
Our solution reduces administrative burden, increases provider cooperation, results in fewer appeals and delivers expedited savings. HMS’ experience allows us to perform high-quality reviews with an accuracy rate that consistently exceeds CMS requirements.
Our solutions can be customized to handle a broad range of needs, including:
- Medical Drug Review
- Outpatient Therapy
- Place of Service
- Inpatient Psychiatric Facility
- Inpatient Rehabilitation Facility
- Skilled Nursing Facilities
- Diagnosis-Related Group (DRG) Coding and Clinical Validation Review
- Automatic Implantable Cardiac Defibrillators