Cost Outlier/Charge Audits

NYCHSRO/MedReview offers expert, independent medical billing audits to clients wanting to ensure that charges match actual care and services delivered.

WHAT IT IS:

  • For claims paid based on total or percent of charges or cost outliers, NYCHSRO/MedReview’s Billing and Coding compliance services focus on the following two areas

  • Cost Outlier Review: For all submitted outlier payment requests, NYCHSRO/MedReview first validates that correct DRG was assigned and then whether all services were:

    • not duplicative or erroneously billed

    • actually rendered

    • ordered by the physician

    • reviews for Level of Care and Quality of Care Issues

HOW IT WORKS:

  • NYCHSRO/MedReview receives claims to be reviewed for compliance and reconciliation of bill services to medical chart documentation

  • Each line item service is validated to ensure that services were:

    • documented in the record

    • ordered by the physician

  • NYCHSRO/MedReview prepares a service line detail worksheet and summary identifying each service billed with notation of compliance or non-compliance and reason for non-compliance finding

  • The audit worksheet and summary are submitted to provider with notice of rights to appeal and a request for sign off agreement

  • Once provider appeal timeframes are exhausted NYCHSRO/MedReview advises payer of amount of billed services validated and nonvalidated and overpayment liability

For more information, click here.