Federal and state law enforcement and regulatory agencies routinely request information from health care organizations. There are numerous reasons for such requests that range from routine claims monitoring activities, audits by Medicare Administrative Contractors, fraud investigations by Medicare Integrity Contractors, or even investigations by the Department of Justice. Strategic Management’s consultants work side-by-side our clients to assist them in responding promptly and effectively to meet the scope of the government’s request.
Auditing and monitoring the claims development and submission process is critical for any health care organization. Through effective claims auditing and monitoring, health care organizations can identify risk, and implement controls to manage these risks. Strategic Management employs a systemic approach to auditing and monitoring that is tailored to the uniqueness of each organization we work with.
The accuracy of a health care organization’s billing and coding is critical for receiving appropriate reimbursement on items and services rendered by their health care professionals. Federal health care program payors issue guidance and billing rules that health care organizations must comply with. Strategic Management assists health care organizations in understanding these billing and coding rules, and further assists with implementation of policies and procedures to help sustain long-term compliance.
Strategic Management’s health care claims data analysis and review services enable health care providers to identify trends in their data, analyze claims for reimbursement and implement improved billing and coding procedures. Our experienced consultants and claims auditors are the nation’s leading experts in data analysis using RAT-STATS statistical sampling.
Strategic Management assist health care organizations in conducting claims review. Strategic Management often is engaged as an IRO to work with health care clients under a CIA to comply with the claims review requirements. The claims review service examines the controls in place to ensure all items and services billed to Medicare or a state Medicaid program are medically necessary, appropriately documented and coded and billed in accordance with standards.