MEDICAL REVIEW AND COMPLEX CLINICAL AUDIT
• Prepay
• Postpay
• Appeals
• Investigate
• Coding and Billing
• Overpayment Calculation
• Fraud Identification.
Review Areas of Specialty
We conduct reviews in all specialties. Some high cost areas are listed:
• EM Codes
• SNF
• Sober Homes / Substance use
• UDT Lab
• Specialized Medications / Cancer Blood Tests
• PCS
• Radiology Tests
• Ambulance / Air Transport
• Wound Care
• Pain Management Intervention
• Renal Dialysis
• Dental
• OB/GYN
• Telehealth more…
Medical Review Scope
Our Medical Review scope is extensive and include:
• Hospital Care
• Inpatient Rehabilitation
• Nursing Home
• Home Personal Care
• Addiction Care Management
• Laboratory
• Radiology
• Pharmacy / Medication
• Home Health
• Sober Homes
• Pain Management
• And more…
Team Qualifications
Our team is composed of:
• Investigation Professionals
• Medical Doctor Specialists
• Registered Nurses / Auditors
• Certified Specialty Coders
• Technical Administrative Assistants
• Information Technology Specialists
Team Capacity
We are able to expand our team based on the needs of our clients. Our medical reviews focus on the detection of:
• Inappropriate billing
• Incorrect reporting of diagnoses
• Billing unnecessary medical services
• Over-utilization of services
• Misusing of codes: upcoding, unbundling
• Billing for services not rendered
• False billing
• Illegal practice of medicine
• Misrepresenting services provided
What makes HCRG Medical Review Services different?
• Our best class medical review methodology and highly credentialed staff.
• Our highly specialized team.
• Our ability to conduct a broad scope of service review.
• Our ability to work with complex and specialized review.
• Our ability to utilize claim and review data to determine FWA practice pattern.
• Our knowledge and experience in fraud, waste and abuse management.
• Our ability to partner and work well with the SIU team.
• Our ability to educate provides of all specialties.
• Our ability to work with OIG, DOJ, FBI.
• Our ability to support SIU in litigation.
Our deliverables
• Evidence based, data driven medical reviews
• Customized reports per clients specification
• Medical necessity / Clinical appropriateness reports
• Data validation reports
• Timely delivery of reports
• Communication with SIU Teams
• Education