Medical review and audit

Research

Retrieval and organization: Requesting, retrieving, sorting, organizing, and categorizing medical records (including hospitalization records, medical history reports, lab results, etc.).
Interpretation and summarization: Deciphering medical terminology, creating accurate medical timelines, generating case summaries, and highlighting key information relevant to a specific case or audit.
Identification of discrepancies: Pinpointing errors, inconsistencies, or omissions in patient records and comparing documentation with coding and billing practices.

Accuracy verification: Assessing the accuracy of medical coding (CPT, ICD-10-CM, HCPCS Level II) and billing practices to ensure compliance with regulations and payer guidelines.
Compliance with regulations: Ensuring adherence to federal and state laws like HIPAA and the Affordable Care Act (ACA), as well as payer- specific policies.
Fraud and abuse detection: Identifying potential issues like upcoding, unbundling, double billing, or billing for medically unnecessary services.
Revenue cycle management: Optimizing billing processes, reducing claim denials, and maximizing reimbursements for healthcare providers.

Internal and external audits: Conducting regular internal audits to identify potential risks and vulnerabilities, and preparing organizations for external audits by government agencies (e.g., Medicare, Medicaid) and insurance companies.
Risk assessment and mitigation: Identifying potential risks in healthcare service delivery and providing recommendations to enhance patient safety and minimize legal or financial risks.
Education and training: Educating providers and staff on documentation guidelines, coding accuracy, billing procedures, and regulatory compliance standards.

Medical necessity reviews: Validating the medical necessity of services and procedures based on clinical documentation and established guidelines.
Peer reviews: Providing an independent assessment of the quality of clinical care by specialty-matched physician reviewers.
Utilisation review support: Reviewing cases for utilization management, peer review, and case management.