Review Types

Recovery Audit Solutions, Inc. (RASI) can review a host of services, including but not limited to medical chart review, DRG validation and medical necessity of admission. RASI reviews the appropriateness of billing by looking for excessive units billed, code definitions, medically reasonable limits or limits imposed by policy. RASI also reviews to make sure all coding was correctly billed, which includes review for unbundling of services, duplicate billing, and inappropriate modifier usage.

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Appropriateness of Billing

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Correct Coding

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DRG Validation

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Outlier Review

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Medical Necessity of Admission

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Medical Necessity of Services

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Medical Chart Review

 Case Study

DRG Clinical Validation Review

– Case Description

Clinical validation reviews are based on documentation noted within the patients’ medical records. RASI collaborates with our clients to create clinical policies for specific diagnoses and procedure code requirements. Using those policies, RASI applies their proprietary algorithms to identify coding irregularities in the claims data.

Summary

RASI audited a medical record to confirm the documentation adhered to the clinical criteria requirements in the client’s policy. Documentation did not adhere to the client’s clinical criteria resulting in an overpayment.

Benefit

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$18,888.12 dollars recovered

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Improved internal processes

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Increased future revenue

Final Result

Original Payment Amount:  $30,285.14
New Payment Amount:  $11,397.02
Savings:  $18,888.12