Hospital/Physician Network Discount Validation Audits

It is difficult in a complex healthcare environment to validate that all commercial payers are paying according to the contract terms.

HCCI will identify payment errors and assist in the recovery of overpayments for the hospital/physician.

Programs and custom editing developed by HCCI will be utilized to determine the payment accuracy by third party payers. HCCI examines health plans’ pricing contracts to validate the reimbursement of each claim. HCCI’s audit will identify:

  • Payment calculation errors in contract exclusions, DRG/APC rate applications.
  • Case rate and Outlier calculation errors.
  • Contract terms calculation errors.
  • Payment calculation errors based on patient status and overlap of services.
  • Retro Adjustment Errors from payers.

HCCI has identified and assisted in the recovery of significant revenue for its clients that would not have been identified in the normal Accounts Receivables management process. The majority of hospitals today have installed contract management software and have assigned staff to monitor and validate payments that edit for further investigation. Hospital staff in most facilities are assigned multiple responsibilities and are not assigned adequate time to perform a thorough investigation of payment discrepancies identified by the contract management software. HCCI’s audit program is designed to assist in the review of all third party payments as well as assisting in the recovery process.