Hospital Bill Audits

SCIOinspire’s hospital bill audit program is a customized service designed to validate the proper payment of hospital bills for payers. The program conducts a line-by-line comparison of the itemized bill to the corresponding medical records and to verify that all services, medications and procedures provided to the patient were physician ordered and charged accordingly.

To optimize savings and increase accuracy of selection, SCIOinspire develops customized claim filters for the client’s particular demographics and contractual obligations. Historical data shows that our auditors identify billing errors in 95% of the audits conducted. Audits are performed on-site at hospital and result in an agreement being executed by the hospital representative in 98% of the cases. Our past experience shows that SCIOinspire’s HBA program have resulted in an average recovery of 5-10%.

Our highly qualified team of Nurse Auditors command over 15 years of hospital audit experience in performing in-depth review, validation of hospital bills and patient’s medical records to ensure accuracy in hospital reimbursements.

APC Validations

SCIOinspire’s APC validation program focuses on identifying inappropriately coded APC claims that materialize due to CCI violations, incorrect usage of modifiers, lack of relevant experience and knowledge in LMRP and LCD guidelines.

This audit program is designed to be conducted as either a desk or on-site audit. The focus of these audits can be determined by client’s identification of a specific facility, APC code, status indicator and/or modifiers. In addition, Provider contract language and Medical Records are thoroughly reviewed and recoded to ensure validity and accuracy of coding, reasonableness of services to the diagnosis, and validity of any observation services.

SCIOinspire’s APC validation team comprises of experienced coders (CCS, CPC-H, and RHIT/RHIA) possessing an average experience of 15 to 20 years in health care and claims management. Our quality assurance process ensures that coders maintain a 95% audit accuracy rate.

Financial Transaction Audits (Data-Mining)

SCIOinspire’s Financial Transaction audit program is a comprehensive review of paid health insurance claims that assist insurers in identifying and collecting incorrect payments from/to providers. It also provides a valuable internal review of current claims adjudication and review processes.

SCIOinspire’s primary objective is to assist clients with the identification and collection of overpaid claims that include, providing of valuable assessments and recommendations that are designed to prevent future overpayments and an assessment of existing claims recovery programs. This allows senior management to evaluate the effectiveness of current cost containment procedures.

High Cost Drug Audit Program

SCIOinspire’s High Cost Drug (HCD) audit program is designed to closely scrutinize and assist in the control of continuously increasing pharmaceutical costs in the following ancillary settings:

Our highly qualified and experienced HCD Audit team performs either on-site or desk reviews by utilizing claims data and medical records. Our auditing team comprises of pharmacists, certified pharmacy technicians, certified coders, and home infusion claim processing professional who have an average of 15 to 20 years of healthcare and claims management experience.

Durable Medical Equipment Audit Program

SCIOinspire’s Durable Medical Equipment (DME) audit program involves the verification of specifically selected DME claims, detailed review of provider contracts and medical records to determine if the services are provided as ordered by the physician, billed appropriately by the provider and are paid accurately by the payer.

Key Focus areas of our program:

This program can be conducted at desk or an on-site based on specific claim or project required by the client. DME audit program is handled by our highly qualified and experienced DME audit team comprising of auditors with an average of 15 to 20 years experience in DME claims processing. They have expertise in clinical components (respiratory, therapy-related), claims review (coding), CMS guidelines, as well as vast knowledge in different types of equipment and the ever-changing technology that drive them.

Skilled Nursing Facility Audit Program

The Skilled Nursing Facility (SNF) audit program is designed to be conducted either as an on-site or desk audit. The audit focus can be designed on a patient specific or a facility focused basis.

SNF audit program ensures that appropriate revenue code has been assigned based on contract language and requirements. By performing a comprehensive review, the SNF audit program compares the bill submitted by the SNF with SNF's contract, the client and the patient's medical records. By doing so the SNF audit program validates the service offered and identifes billing errors due to inappropriate revenue codes.

DRG Validations

SCIOinspire DRG Validation program aids Payers in recovering incorrectly billed DRG claims. DRG claims rely exclusively on documented and treated diagnosis. Coding errors majorly prevail unless the coders are familiar with the new system brought by the introduction of Medicare Severity DRGs.

SCIOinspire’s audit process consists of thorough reviewing and recoding of the medical records to ensure the validation of coded procedures and diagnoses that are a part of the DRG billed by the provider and reimbursed by the payer. Subsequently, through the use of nationally accepted technology, National Audit recodes and re-prices the claim based upon the audit results, thereby providing clients with accurate and validated payment information for each claim.

Key Focus Areas of SCIOinspire’s DRG Validation Program:

SCIOinspire’s DRG audit staff comprises of experienced coders (CCS, CPC-H, and RHIT/RHIA) commanding an average experience of 15 to 20 years in the health care and claims management. Our Quality Assurance Process ensures that coders maintain a 95% audit accuracy rate.