Retrospective Review

Utilization management may occur after care is provided, and usually after payment is made on the claim. This process, known as retrospective review, validates various aspects of a claim against the medical records, and the difference between the payment made and the correct payment is calculated for recovery. Retrospective reviews can either be conducted on claims selected at random, or on claims that are the  most likely to contain errors.

We review over 100,000 charts each year.

This type of review has the highest return on investment of any utilization management process. And, depending on how the payer handles the recovery, it can also impact provider behavior, resulting in more appropriate resource utilization and reduced costs for future services.

Types of Retrospective Review

  • Coding Review/DRG Validation: A Coding Review is performed when a reimbursement is based on diagnosis and procedure codes, such as Diagnosis Related Groups (DRGs). A Certified Coding specialist will verify that a patient’s symptoms match the diagnosis (ICD) and procedure codes (CPT) in effect at the time of discharge to calculate the claim being billed.  Our panel of expert Physician Reviewers can also validate the codes according to the submitted clinical information if requested.

  • Appropriate Setting: A registered Nurse Reviewer will review a patient’s medical records to determine whether the acute hospital (or other) level of care or services provided were appropriate. Whenever one of our registered Nurse Reviewers is unable to approve the issue, the case is referred to a Physician Reviewer for determination.

  • Billing Error: A registered Nurse Reviewer or credentialed Coding Specialist will review medical records to determine if a service was billed appropriately according to each payer’s directive.

  • Quality of Care Review: Quality of Care issues are often identified when reviewing medical records for other issues, such as medical necessity. If a Registered Nurse Reviewer identifies a quality of care issue, a Physician Reviewer will evaluate the claim, verify or resolve the concern, and assign a severity level. Quality of Care Reviews provide the information needed to help change a practice or policy when the care delivered does not meet quality standards.

  • Medical Bill Audits: Medical bill audits are a critical tool for ensuring the efficient and appropriate use of healthcare dollars. Submitted healthcare claims are compared side by side against medical records to verify that the treatment claimed for reimbursement was actually performed. Issues of unbundling (billing separately for services that should be billed as a single item); incorrect coding of procedures, including compliance with NCCI edits and other standard coding procedures; and others are routinely discovered.

  • Our Certified Coding Specialists, Registered Nurses, auditors (including Certified Fraud Examiners when appropriate), physicians, and other healthcare professionals apply proprietary algorithms to deliver a high return on investment for our clients.