Medical Record Audit

HCRS IS HELPING PAYERS AND PROVIDERS ACROSS THE NATION ENSURE ACCURATE PAYMENT. WE CAN HELP YOU WITH YOUR MEDICAL AUDIT WORKLOAD, TOO — DEPENDABLY, RESPONSIBLY, AFFORDABLY. ASK US HOW!


Medical record audit is the centerpiece of any healthcare program integrity initiative. 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.

Our medical record audit clients run the gamut from not-for-profit, Defense Department and Veterans Health Administration hospitals to physician groups to State government agencies, a Recovery Audit Contractor (RAC), a Medicare Administrative Contractor (MAC) and a Medicaid Integrity Contractor (MIC). We average $8 in incorrect payment identification for every $1 invested in HCRS medical record audit.We average $8 in incorrect payment identification for every $1 invested in HCRS medical record audit.

  • Coding review operations. We have inpatient and outpatient coding auditors, all AHIMA-recognized 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-recognized or AAPC certified.
  • 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.
  • We specialize in DRG validation. Our experience includes multi-year DRG coding audits and medical necessity reviews for a Recovery Audit Contractor (Performant Recoveries); for a hospitalist physician practice (Fredericksburg Hospital Group); as subcontractor to Health Management Systems (HMS), for the Commonwealth of Virginia Department of Medical Assistance (DMAS); As subcontractor for OptumInsight/United Health Group, for the Maryland Health Services Cost Review Commission (HSCRC); and in support of Palmetto GBA, a Medicare Administrative Contractor (MAC). For Palmetto, we performed medical record audits to ensure the accuracy of Medicare DRG assignments and sequencing and also for the Comprehensive Error Rate Testing (CERT) program, under which we contributed to Medicare’s national error rate calculation by independently auditing a sample of “live” cases prior to payment.

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

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