Audit Advantage® Overview

Clinical (also known as complex) claim audits require review of medical records or other source documentation to substantiate coding and billing of medical claims. Performant Healthcare Solutions^® offers a comprehensive suite of clinical review audits proven to generate post-payment recoveries and prepayment savings. In the course of conducting these audits, Performant will identify claims potentially paid in error, request provider medical records for selected claims, receive and process all medical records (e.g., paper records, CDs or DVDs received through mail processing, as well as electronic submittal through fax or Performant’s secure provider portal), conduct the clinical audit by appropriate staff, develop clear findings (if any), document the findings’ rationale, process and mail the results letter, and handle all provider communications throughout the process. Our solution includes dedicated lockbox services offering complete end-to-end processing and accounting and integrates optical character recognition (OCR) to scan and digitize documents received by mail, maintaining a detailed account record.

Performant’s complex/clinical review audits are segmented into categories spanning a broad range of claim types, ensuring each client’s high-risk claim categories are being monitored for potential overpayments. These categories include:

• Inpatient: Diagnosis Related Grouping (DRG) Coding & Clinical Validation (both MS, APR and variants), Long Term Acute Care Hospital, Inpatient Rehabilitation, Skilled Nursing Facility, Readmission, and Short Stay (or Place of Service)
• Outpatient: Ambulatory Payment Classification (APC), Ambulatory Patient Groups (APG), Professional (such as percent of charge, fee schedule, or other line payment methods), and Ambulatory Surgical Centers (ASCs)
• Post-Acute Care: DMEPOS, Home Infusion Therapy, and Home Health
• Specialty Audit: High Cost Drugs and Clinical Labs (especially Pathology, Genetic Testing)

We understand the challenges associated with ensuring quality patient care, managing a network of providers, and maintaining a healthy Medical Cost Ratio (MCR). We offer a complete suite of payment integrity services designed for payers looking to get more from their outsourcing partners. Whether you’re a large national health plan, local regional plan, or government agency – we have the experience to deliver a payment integrity program tailored to your unique goals and requirements.

Our audit and recovery services offer:

• Experience from national CMS RAC programs and commercial payers representing more than 200MM+ covered lives
• Fast program implementation for accelerated recovery and ROI
• High accuracy and customer service ratings, with a focus on protecting critical provider relationships
• Proprietary technology, online program reporting and dedicated teams focused on building long-term partnerships

Another distinction of Performant’s audit services is our commitment to provider outreach on behalf of our health plan clients. Performant’s dedicated customer service call center performs outreach calls to providers to ensure the audit programs are introduced and explained, medical record requests are received and understood, and remind providers of pending deadlines. Performant also fields tens of thousands of provider phone calls. Our customer service representatives answer or return calls in a timely manner and are equipped to increase our first-call ability to answer or resolve provider inquiries.