Claims Reviews

Strategic Management assists 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.

Claims Review Services

Strategic Management’s team of certified coders and nurse auditors perform claims review for health care organizations, and frequently for organizations under CIAs. The scope of our claims review is a random sample of claims that were reimbursed by Medicare or a state Medicaid program. The objective of our review is to determine whether the items and services furnished were medically necessary and appropriately documented, and whether the claim was correctly coded, submitted and reimbursed. Specifically, when Strategic Management is acting as an IRO, the claims review will be conducted and scoped in accordance with the CIA.  

Claims Review of Overpayments

Strategic Management works with health care organizations to review paid claims that resulted in an overpayment. Additionally, we examine the system, policy and process in placed that generated the claim. Our team of consultants and certified coders identity weaknesses that may have resulted in the identified overpayments and we make recommendations for improvements to the system, policy and process to the claims development and submission process.

Claims Review Report

Strategic Management prepares a robust report that details qualitative and quantitative results, including our claims review methodology, the scope of claims universe, objective of the review and our findings and recommendations. The claims review service report includes recommendations for improvements to the billing and coding system or to controls for ensuring that all items and services billed to Medicare or a state Medicaid program are medically necessary and appropriately documented.

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