Outpatient Audits

Audit Advantage^® for Outpatient helps health plans identify improper payments for the spectrum of outpatient claims while protecting critical provider relationships. Our scalable, comprehensive outpatient audit program protects plan dollars and improves plan oversight of the broadest range of claims, including Ambulatory Payment Classification/Ambulatory Patient Group (APC/APG), Professional (percent of charge, fee schedule, or other line payment method), and ambulatory surgical center (ASC). This program was designed to address several problems with these claims:

• By 2029, outpatient services are projected to increase by 14.8%, whereas inpatient volumes are expected to decrease by 1.0%
• Packaging codes under a single APC/APG creates less opportunity to identify audit findings
• Complex CPT weighting and ever-changing payment rates make it difficult to maintain information and identify coding anomalies
• Validity of pre-authorized services cannot be determined until service is rendered and medical records are reviewed

Performant Healthcare Solutions^® deploys a team of clinical audit experts who perform medical record reviews with speed and accuracy to optimize audit findings and recovery efforts, as well as perform level of coding reviews to identify and amend incorrect CPT codes, resulting in a lower APC/APG level. We deliver audit findings with a high rate of accuracy to boost recoveries and reduce provider burden for the health plan. Our proven outpatient audit program typically achieves savings up to $6 PMPY for Medicare Advantage plans and $4 PMPY for commercial plans