Post Inpatient Claim Review

The Goal, The Gap, The Solution, and Sample Services!

Goal

To maximize reimbursement for inpatient services, including post inpatient claim review utilizing experienced physician reviewers with extensive training in billing and coding guidelines to bridge the gap between provider clinical documentation and the coding and CDI department. Other goals include improved compliance and the Case Mix Index.

Gap

Accurate coding for inpatient services requires both detailed clinical documentation by providers as well as experienced coding staff. The potential to achieve maximum reimbursement is limited by several factors. Coding staff often have non-clinical backgrounds and are held to strict coding guidelines. Physicians have limited time for documentation and are not trained to document. Hence, there is a great opportunity to capture more accurate and additional diagnoses as well as procedure components that would increase not only reimbursement but also improve compliance and Case Mix Index.

Solution

Our U.S. physician reviewers analyze medical records to ensure all billable diagnoses and procedures are captured and coded in accordance with the most up-to-date clinical and coding guidelines. Their training allows them to quickly identify opportunities to maximize coding and engage hospital physicians through the creation of physician queries.

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Sample Services

  1. Medical Record Review by US-trained Physicians:
  • MSDRG assignment
  • APRDRG assignment
  • Quality Reviews:
  • Risk of Mortality
  • Severity of Illness
  • Hospital-Acquired Conditions
  • Patient Safety Indicators
  • Present on Admission conditions
  1. Data Analysis and Reports, including identification of coding and documentation trends that affect reimbursement
  1. Creation of physician queries
  1. Appeals of medical necessity denials, coding denials, and clinical validation denials
  1. Custom Consulting:
  • Physician engagement and collaboration with coding and CDI staff, including case discussion and training as requested
  • Revenue projections and valuations of practices or service lines
  1. NO COST QUICK CLAIM AUDIT (200 – 250 Claims) or 90-day Review.
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