Services

Medical Audit & Clinical Review

  • 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.

Diagnosis Related Groups (DRG)

  • DataMetrix DRG Module automatically chooses the correct version to use based on the discharge date of the claim
  • DataMetrix DRG Module can be used as a standalone or integrated function with your current claim system
  • Calculations are updated in accordance with CMS schedules
  • Minimizes user error

Ambulatory Payment Classification (APC)

  • CMS edits and pricing are utilized.
  • DataMetrix updates edits, fee schedules and pricing, based on CMS schedules.
  • Pricing references date of service and geographic location
  • Application of DataMetrix proprietary algorithms to flag suspicious claims for additional review

Pre/Post Pay Data Mining Module

DataMetrix identifies areas of revenue recovery on all bill types including, but not limited to:

  • Eligibility
  • Coordination of Benefits
  • Medicare Compliance Edits
  • Duplicate Payments
  • Contract Compliance Review
  • ESRD - End Stage Renal Disease
  • Hospital Acquired Conditions (HAC)

Prepayment Negotiation Module

  • Substantial savings
  • Signed agreements on out-of-network claims
  • No balance billing of members for discounted amount
  • Exceptional provider relations
  • Turnaround time 5 days

Recovery

  • Staff of experienced and professional recovery specialists
  • Broad knowledge of the industry
  • Extensive experience
  • Responsive specialists at DataMetrix work tirelessly with providers making sure that the maximum amount is collected