Part C Claims Audits
Of every dollar, 85 cents is spent here.
If you are concerned about your ability to pay Part C claims correctly, GHG will review your provider reimbursement policies, compare them with CMS requirements, and perform sample reviews of actual adjudicated claims to determine if the proper payment policy is being applied.
In addition to meeting these near-term goals, we will also pay particular attention to your plan's ability to “pay as Medicare pays” as well as all adjudication phases in the life cycle of claims processing.
In order to do this, GHG will review claims samples within each of 35 provider categories that meet the following disposition:
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Fully paid appropriately
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Fully denied appropriately
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Full or denial with subsequent provider pricing complaint
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Partial denial (including line item denials)
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Formal claims payment appeals and provider initiated adjustments
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Inappropriately paid claims (random sample for discovery)
We can provide analysis on a statistically valid basis, or hone in one specific areas of concern with a sample--- which can yield meaningful results at a fraction of the cost. Depending on our findings, we will then work with you to establish Medicare-appropriate policies and procedures, train staff, and help you find tools that serve you better.
