Medical Record Audit
HCRS is helping Medicare, Medicaid and hospitals across the nation ensure accurate payment. We can help you with your medical audit workload, too -- dependably, responsibly, affordably. Ask us how!
HCRS has complete, conflict-of-interest free capability to perform medical audits across the spectrum of healthcare organizations – coding and DRG validation, medical necessity determination, or both in a complete “complex review” solution. We have experience with both desk audits and field audits. For our current customers, we are obtaining and scanning records, interfacing with customer claims control applications, reviewing inpatient, outpatient, dental, pharmacy, behavioral health and other ancillary services coding for accuracy and sequencing; reviewing medical necessity; and, for payer clients, supporting appeals as necessary. We average $8 in incorrect payment identification for every $1 invested in HCRS medical record audit.
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Coding review operations. We have inpatient and outpatient coding auditors, all AHIMA or AAPC certified and all with at least 5 years coding and 2 years auditing experience. For pharma and dental claims, our auditors are pharma techs or dental-certified as well as AHIMA or
AAPC certified. We are ahead of the curve on ICD-10, and have 8 AHIMA-certified ICD-10 coder/auditor/trainers on staff.
- Clinical review operations. This is the medical necessity determination. Our nurse auditors have a minimum of five years utilization review or audit experience. We have two DDSs on call to review dental claims as called upon. Our Medical Director, who signs off on all medical necessity denials, is Board Certified by the American Board of Quality Assurance and Utilization Review. He has more than 15 years experience as a Medical Director and Senior Medical Director responsible for prior authorization, concurrent review, and claims review.
Audit history. HCRS has been providing payment integrity services since 1998, when we began doing coding validation audits and medical necessity determinations for the City of Baltimore Workers Compensation program. Federal clients for validation audits have included the Veterans Administration (2001-2003) and the Air Force’s Air Education and Training Command (2001-present). Current Medicaid and Medicare subcontracts are as follows below. Overall, since the beginning of the Audit Medicaid Integrity Program, we have performed over 1,000 reviews and identified over $20 million in incorrect payments to Medicaid providers.
CURRENT MEDICAL RECORD AUDIT CUSTOMERS
| Prime Contractor | Program | Scope of Work | Work Began |
|---|---|---|---|
| HMS-IntegriGuard | Audit MIC, 22 states west of Mississippi and three territories | Coding validation; medical necessity determination; field audits as directed | 9/09 |
| HMS-Permedion | Virginia Medicaid | DRG validation | 11/09 |
| HMS-Permedion | Virginia Medicaid Behavioral Health | Coding validation; medical necessity determination | 10/09 |
| OptumInsight | Maryland Medicaid | Inpatient diagnostic coding validation | 9/08 |
| Palmetto GBA | Medicare for several states and territories | Pre-pay DRG validation for the CERT (Comprehensive Error Rate Testing) program | 12/11 |