Clinical Auditing

Adreima’s Clinical Auditing Team integrates technical, clinical and legal perspectives to review and audit challenging accounts to find additional revenue for hospital clients. For over 20 years we have provided custom auditing services for our clients, focusing on increasing reimbursements and reducing recoupment. Audits are performed by highly trained Nurse Auditors and Certified Coders. In addition, by utilizing proprietary systems, we are able to identify and facilitate resolution of systemic issues to minimize repetitive errors.

Benefits Include:

• Identification and collection of additional revenue that was under billed or denied
• Defense against recoupment and audits by regulatory agencies
• Claims resolution using all available clinical, technical and legal avenues
• Ability to work a claim from assignment through to payment across all of Adreima’s service lines
• Extensive data analysis and reporting to identify the key areas of focus that result in the largest impact for the hospital
• Reporting and consulting to aid in process redesign to prevent future problem

Commonly Conducted Audits:

Adreima conducts a variety of different clinical audit reviews on behalf of client hospitals. Our audits are customized to meet clients’ specific needs and remain flexible to accommodate variation. The most commonly conducted audits are:

• RAC appeals (and other regulatory agency/audits) – Management of the entire (or any portion of) RAC appeal process, including initial clinical review to determine which claims are appropriate for appeal prior to recoupment action, as well as expertly prepared appeals at every level needed. Additionally, cinical review and appeal for any claim that has had a request for recoupment and/or is under review from a regulatory agency (i.e. OIG).
• Concurrent and Utilization Review – Clinical review of medical records done while the patient is still in-house. Communication directly with payors to providing clinical information and obtain authorization for payment. Provide immediate feedback to the hospital clinical care team, and relieving internal case manager work load.
• Charge Hold/Loss Charge Audits – Clinical, coding, and line item charge review completed during the Discharged Not Final Billed (“DNFB”) period, done with a special emphasis on identifying over/under charges to ultimately ensure appropriate billing and coding.
• Level of Care Audits – Clinical review of medical records done with particular consideration for the unique, technical, clinical and regulatory concerns of the identified population. Specialized expertise in Neonatal Intensive Care Unit auditing.
• Defense Audits – Review of line item charges and defense of the hospital when health plans disallow charges for commercial contract payors.
• Stop Loss Audits – Line item charge review of all over/under charges on claims that are within a statically small margin of a contractual or regulatory break point that could potentially impact payment (i.e. outlier).
• Carve Out Audits – Clinical and line item charge reviews looking for specific contractual or regulatory items, procedures, events, or services that could potentially impact payment (i.e. particular surgical implants).
• Pre-Bill Audits – Clinical, coding, and line item charge reviews done during the DNFB period to ensure appropriate billing and coding.

Our Clinical Auditing Team can handle overflow, special circumstances, or backlog projects to meet your needs. We have the ability to complete audit work off-site, with all activity documented on the hospital’s patient accounting system for convenience. Based on the needs of the hospital, our fee structure can be either hourly, project based or based on a percentage of recoveries.