Claims Audit Tool

An effective claims audit process is critical for all healthcare payers

The need for an effective and efficient claims audit process is critical for all healthcare payers, across lines of business including self-insured, Medicaid, Medicare, Medi-Cal, and commercial plans. With constantly changing reimbursement models, regulations, and rising costs, there is an increased need for proactive identification of issues that affect accurate claims adjudication and compliance. The Claims Audit Tool™ (CAT) is the solution that finds claims which require intervention and can streamline and automate the necessary steps to correct the errors, improving process quality and payment accuracy. CAT scans claims both prepayment and post-payment to identify anomalies and address them based on your business requirements.

CAT is user friendly, intuitive, and low maintenance. The tool works with multiple claims systems, can be quickly implemented, and is flexible and scalable. Clients realize savings from avoiding payment errors and subsequent rework ranging from hundreds of thousands to millions of dollars annually.

Audit Scenario examples include:

Timely filing reductions and denials
Correct denial code used (CARC/RARC)
Pricing/payment is consistent with contract terms
Verify correct financial responsibility (DOFR, shared risk)
Multiple procedure discounts properly applied
Validate claims with multiple copay amounts on the same date of service were processed accurately

Validate services were consistent with authorization
Copays, coinsurance, and deductibles properly applied
Focused audits on known risk areas (high dollar claims, providers, retro fee schedules, etc.)
Random sample audits (on examiners, auto-adjudicated claims, etc.)
Duplicate claims

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CAT Features and Benefits

CAT provides a 360 degree audit to comprehensively review at all areas that impact claims payment and processing accuracy. Some key features and benefits include: