Healthcare Claims Review Services

Develop Robust Controls to Improve Program Integrity

Up to 80% of healthcare claims contain errors – resulting in billions of dollars in overpayments every year. Do you have proper controls in place to avoid these errors, maintain program integrity, and ensure compliance? 

Strategic Management Services examines your controls and recommends improvements to your processes. We are often engaged as an Independent Review Organization (IRO) to work with healthcare clients under a Corporate Integrity Agreement (CIA) to comply with claims review requirements. 

How it Works

A Proven Process to Reduce Claims Risk

• Assessment Phase
  Our team of certified coders and nurse auditors performs claims reviews. We use a random sample of claims that were reimbursed by Medicare or a state Medicaid program to determine whether the items and services furnished were medically necessary and appropriately documented, and whether the claim was correctly coded, submitted, and reimbursed.
• Processes Analysis
  We work with healthcare organizations to identify and analyze claims that result in an overpayment. Additionally, we examine the system, policy and process in place that generated the claim – helping us identify weaknesses and make recommendations for improvements.
• Review Report
  Our team prepares a robust report that details qualitative and quantitative results, including our claims review methodology, the scope of the claims universe, the objective of the review, and our findings and recommendations.