Clinical (Complex) Review Audits

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Clinical (also known as complex) claim audits require review of medical records or other source documentation to substantiate coding and billing of medical claims. Performant offers a comprehensive suite of clinical review audits proven to generate post-payment recoveries and prepayment savings. In the course of conducting these audits, Performant identifies claims potentially paid in error, request provider medical records for selected claims, receive and process all medical records, conduct the clinical audit by appropriate staff, develop clear findings (if any), document the findings’ rationale, process and mail the results letter, and handle all provider communications throughout the process.

Performant’s complex/clinical review audits are segmented into categories spanning a broad range of claim types, ensuring each client’s high-risk claim categories are being monitored for potential overpayments. These categories include:

  • Inpatient: Diagnosis Related Grouping (DRG) Coding & Clinical Validation (both MS, APR and variants), Readmission, and Present on Admission
  • Outpatient: Ambulatory Payment Classification (APC), Non-APC payment structures (such as percent of charge or case rate), and Ambulatory Surgical Centers (ASCs)
  • Transitional Care: Long Term Acute Care Hospital, Inpatient Rehabilitation, and Skilled Nursing Facility
  • Post-Acute Care: DMEPOS and Home Infusion Therapy, Home Health, and Hospice
  • Specialty Audit: High Cost Drugs/Specialty Pharmacy and Clinical Labs (UDT, Pathology, Genetic)