DataMetrix Medical Audit & Clinical Review Module

DataMetrix has a staff of board certified physicians with specific expertise in claim review from medical necessity and coding perspectives. Our skilled and Certified Medical Audit Specialists provide high-value medical review activities.

• HBA – Hospital Bill Audit
• Desk Audit
• Physician Claim Audit
• Training and Program Development
• Partial Claim Denials

The Hospital Bill Audit: Is the line item review of the hospital’s billed charges against the patient's medical record. This audit is a post-payment bill review and is performed on-site at the hospital. Each individual billed charge is checked to determine that there is a corresponding physician order for the particular service and the identification of any items that may have been unbundled as per Center for Medicare and Medicaid (CMS) guidelines.

DataMetrix identifies overcharges and validate the undercharges presented by the hospital audit representative. The audits are performed on-site at the hospital by Registered Nurse (RN) Certified Medical Audit Specialists (CMAS). An agreement is obtained from the provider at the conclusion of the audit.

The Desk Audit: Is the line item review of the hospital bill. It is done with or without the medical record and pre or post payment. It identifies overcharges similar to the HBA service above; but when performed pre-payment, it becomes a negotiation tool.

Physician Claim Audit: Is a data review and or clinical medical record review. It identifies E & M coding discrepancies and using NCCI edits, identifies unbundling and overcharging.

Training and Development: DataMetrix’s Medical Audit Academy trains medical auditors and client staff on clinical review including Hospital Bill Audit; ICD-10; E & M Audit.

Partial Claim Denials: DataMetrix Board-Certified physicians determine when emergent care ends and repatriation should have begun.

Benefits

• The hospital bill audit is extremely beneficial to identify that billed services were delivered to the patient and also that services were charged at the appropriate rate.

• DataMetrix will identify overcharges and validate the undercharges presented by the hospital audit representative.

• The audits are performed on-site at the hospital by Registered Nurse (RN) Certified Medical Audit Specialists (CMAS).

• Following the completion of the audit, all findings are reviewed with the appropriate hospital personnel to achieve concurrence with the audit findings.

• An agreement is obtained from the provider at the conclusion of the audit.