Overview


Significant errors are made in processing healthcare claims every day. Duplicate charges and other billing mistakes from hospitals and other providers often go undetected. Discounts available through PPO Network are often missed or miscalculated, resulting in large overpayments. Coordination of Benefits (COB) and other third-party liability opportunities such as subrogation go undetected. All of these result in over-payments - costs that impact your bottom line. Our Quality Assurance Services addresses issues of overpayments and adherence to applicable compliance standards.

The Quality Assurance Services is responsible for ensuring compliance with applicable healthcare claims standards and regulations through process review, approval, audits and systematic maintenance of quality systems. The scope of activities includes production and process controls, change management, validations, system testing, risk management, procedural review and creation, and process improvements.

MDI NetworX has been able to recover millions of dollars in overpayments for their clients, as well as ensure long-term process health by finding and correcting root-cause issues.

MDI Advantage


Review Compliance Rigor

Test Routines & Controls

Drive Process Improvement

Training Needs Identification

Recover Claims Overpayment

Capabilities


Our experience & extensive knowledge of auditing medical claims has placed us at the leading edge of firms addressing billing errors & payment integrity. We employ rigorous validation, extensive quality checks, robust industry research and ongoing education to ensure we continuously deliver tangible results to our clients.


We are able to

  • Verify if systems and processes are in place
  • Validate coverage of dependents
  • Monitor claims payment accuracy
  • Identify and recover overpaid claims

01

Claims Audit Services – First Pass

Using advanced electronic testing techniques, the first pass assesses all available claims and eligibility data, including claims adjustments and reversals with a focus on determining payment accuracy.

02

Claims Audit Services – Audit the Auditor

The second stage involves close examination of the error logs prepared by the auditors. Individual claims further examined for accuracy by experienced staff may result in audit overpayment followed by review and re calculation for quantifying financial impact. Final audit report is prepared which includes recommendation to address identified process gaps in the audit.

03

Overpayment Recovery Services

We use advanced statistical techniques, including custom data mapping, pattern detection, and regression analysis, to identify situations that are hard to spot at the transactional level and provide significant recovery and prevention opportunities. We help our clients identify, eliminate, and recover overpayments.

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