Services

• Stop loss
• Carve-out provisions
• Non-applied per diem
• Capitated services paid as service fees
• Retroactive rate reductions
• Incorrect level of care paid
• Missed or inappropriate provider discounts
• Episode of care analysis
• Cap on reimbursement

Identification and recovery for other party liability, including other commercial insurance, Medicare, or Medicaid, or other state-sponsored plans.

Obtaining medical charts and health records, either electronically or by scanning hard copies, and then reviewing for improper payments. This can be done post-pay or pre-pay.  Examples include:

• DRG Validation
• CMS to MS DRG conversion
• Outliers
• AP / APR DRGs Classification
• Post acute transfers
• I/P rehab
• Debridement (excisional v. non-excisional)
• Coagulopathy
• Non-par hospital chart review
• Coding errors
• Contract compliance issues
• High cost carve-out services
• Services that could have been provided on an outpatient basis
• ASC/APC list violations
• Drug code review, J&Q codes, verification of dosage
• Lab services-outpatients vs. inpatient
• Dialysis-multiple sessions within one day
• E&M global surgery periods-separate billing
• High density of diagnostic testing
• ESRD-per treatment vs. cap payment
• Elective surgeries canceled but billed
• Incorrect units
• Colonoscopy
• Cataracts
• Cardiac catheterizations

Identification and recovery of duplicate medical claim payments, multiple providers, interim billing and split bills.

Due to complex dosing and administration requirements, most specialty pharmacy is adjudicated under the medical benefit and can represent significant payment challenges for payers.  Unlike the pharmacy benefit where dosing edits are common, many of these same edits to prevent inaccurate payments do not exist in the medical pharmacy adjudication process. 

A thorough audit and understanding of this pharmacy spend can recover past overpayments and allow for future cost containment.

Sample areas of review include:

• Unit conversions (administered vs. billed)
• Costing accuracy
• Diagnosis code vs. billed drug
• Claims paid under both the medical and pharmacy benefit (duplicate payment)
• Miscellaneous HCPC codes
   

More and more payers are realizing that auditing the pharmacy benefit is critical to containing the rapidly increasing pharmacy spend.  When payers outsource the pharmacy benefit to external PBM’s, they are relying on the PBM to adjudicate claims accurately and according to contractual terms, formularies and benefit designs. Because the PBM process is highly automated with little human adjudication, small errors can very quickly add up to substantial overpayments.  A post-payment review of the pharmacy benefit can recover past overpayments and allow for system corrections to prevent such errors from recurring.

Sample areas of review

• Formulary rebates
• Pricing – E.g. AWP, ASP, MAC, specialty, weighted average guarantees, etc…
• Claims paid for off formulary or non-covered drugs 
• Duplicate paid claims
• Claims paid for ineligible members
• Incorrect co-payments applied
• Incorrect days supply
• Incorrect implementation of prior authorization, step therapy, or quantity limits
• Dosing / package size errors
• Dispensing fee verification
• Performance guarantees
• Other areas uncovered during review of the above
   

This encompasses reviewing provider billing in conjunction with payer contracts and payment guidelines to ensure proper payment. Areas include:

• Procedures
• Incidental
• Mutually exclusive services
• Transplants
• Implants
• CPT coding & modifiers
• Bundling and unbundling
• Ambulance related services
• Anesthesia
• Observation
• DRG
• High cost drug analysis
• ESRD
• Quantity differences
• Rate analysis
• Billed unit analysis
• Multiple surgeries
• Assistant surgeon
• Split bill

Determining if claims submitted are for terminated plan members such as:

• Terminated groups and individuals
• State disenrollment

Our reviews include:

·    Formulary, benefit design, client lists, and customer contracts.

·    Clinical review of aberrant unit quantities for each NDC, including verification with dispensing pharmacy.

·    Market share and performance criteria evaluation.

·    Identification of duplicate claims within each submission, across contract entities, and across prior submissions.

·    Reconciliation of invoice and claims detail.

·    PBM site visit to review adjudication process.

·    Root cause analysis and custom audit reporting.

·    Audit results management presentation.