SPECIALIST PHYSICIAN KNOWLEDGE
This knowledge applied to:
REVIEW DETERMINATION TYPES:
Medical necessity, experimental/investigational, benefit coverage determinations, surgical predetermination, length of stay, level of care, appeals reviews, quality of care, fraud and abuse, claims and coding analysis, workers' comp reviews, dental, and disability.
& CODING EXPERTISE
Claims edit and auditing systems are an important part of today's health care payment environment. However, they do not replace the "gold standard" of review of the actual medical records by a practicing board-certified physician of the appropriate specialty. Many claims still require physician-based analysis for coding, utilization and serious quality of care issues. Certified coding specialists, RNs and certified medical audit specialists complement and support the work of our physician specialist panel.
& REFERENCE BASED PRICING
Medicare as well as ERISA plans often require Medicare reference based pricing, post-payment audits and quality of care review. From DRG inpatient reviews to prospective payment skilled care audits in SNF, rehab or home health settings, we provide a full range of Medicare pricing and audit services. Reference based pricing is not a new concept to us, but one that we have practiced for over 20 years.
& FACILITY BILL REVIEW
Primary tools used in network are line-charge verification audit and physician specialist review. Out of network repricing is also performed if needed. Physician specialist and line charge audits depend on review of the actual medical records on the case. DRG reviews include DRG pricing and more commonly DRG Medical Record Validation by board-certified MDs. Other facility areas audited include: outpatient surgery, emergency room, air/ground ambulance and more.
WHO WE ARE AND WHAT WE DO
HealthClaim Solutions® provides full service medical review and hospital/facility audit for healthcare payers and administrators. A large national panel of specialist MDs from over 125 specialties and subspecialties provide medical necessity opinions, medical and surgical pre-certification, claim/coding review, quality assurance peer review, fraud and abuse analysis, Medicare and Medicaid review, behavioral health review, disability and workers' comp review, with coding, claims and bill audit in all areas. Our consultants have a national geographic base. Disability file review is performed for both disability firms as well as ERISA plans. Post payment audits and Medicare and Medicaid audits are also key product areas.
In addition to our core area of medical review, HealthClaim Solutions® has distinguished itself as an industry leader for hospital and facility bill audit. In-house physician specialists differentiate us from traditional bill review and claims audit firms. Our fees are flat rate or hourly and are not contingency-based. Hospital inpatient bills of all sizes are reviewed both in-network and out of network. Physician specialist and line charge audits are commonly performed in network where 95% of today's hospitalizations occur.
We have a group of dedicated claims, coding, and repricing professionals onsite at our main office in Orange County, CA as well a large national panel of physician and other medical specialists.
We serve all health insurance payer markets including ERISA plans, Third Party Administrators, UM/CM, care management, cost containment companies, Blues plans, Medicare Advantage, Medicaid plans, managed general underwriters, stop loss and reinsurers, and disability and workers' comp carriers.
HealthClaim Solutions® is a Considine & Associates company. Considine & Associates is a
URAC-accredited Independent Medical Review Organization.