Medical Record Reviews & Audits
Medical record reviews and audits should be performed by experienced coders or clinicians who understand trends in the healthcare fraud arena. Our team reviews medical record documentation for clinical and coding accuracy, using industry standards such as:
Coding guidelines as defined by the CPT and HCPCS codes
Health plan policy guidance, both internal and external
CMS Policy, NCDs and LCDs
Standards of Care
Thorough and professional reports created by the Integrity Advantage team ensure a level of professionalism and confidence to the investigator, health payer, provider and law enforcement. Medical reviews are accompanied by a summary that outlines specific deficiencies identified during the review. This summary can also be used as a tool to communicate findings for provider education and / or overpayment recoupment purposes. Integrity Advantage provides post-payment or pre-payment claims review as well as support for appeals and pharmacy lock-in initiatives.
Our team also supports:
- Appeals when related to a medical review performed by Integrity Advantage
- Policy gap analysis to identify areas of vulnerability within a health plan
- Creation and improvement of medical policies and edits
- Pre-authorization support for areas more vulnerable to healthcare fraud, waste and abuse
Whatever your FWA needs, our team can help.