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Clinical Review & Resolution

  • Clinical Review & Resolution
  • Hospital Bill Audit
  • DRG Validation
  • Outpatient Audit
Home Clinical Validation Clinical Review & Resolution

Clinical Review & Resolution

Our hands-on inpatient clinical and financial review leverages CMS clean claim principles and focuses on inpatient claims.

This payment integrity solution performs a thorough and comprehensive review of each claim’s itemized bill to identify defects and improprieties. Our payment integrity solution employs sophisticated technology and data analytics in addition to expert clinical review by nurses, physicians, accountants, and certified coders to identify errors and compliance issues before the claim is paid. Once billing adjustments have been identified, our expert resolution team of negotiators and medical professionals work with the provider to explain our findings and come to an equitable resolution.

High-dollar, inpatient reviews can take a few different paths and can be modified to fulfill client needs. At the core of the service is our Prospective Inpatient Claim Review report which identifies line items and amounts to be adjusted prior to payment. Adjustment categories include:

Level of Care

Hospital Acquired Condition

Experimental Drugs & Procedures

Implant Markups

Unbundling

Billing Errors

We support our findings with CMS provider reimbursement guidelines and plan benefit detail, and our team of resolution experts work every claim to resolution with the provider. By working in concert with our clients’ provider relations team, Equian minimizes provider abrasion while leveraging and defending findings.

Exponentially advance your Payment Integrity model by aligning with Equian.

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  • Home
  • About
  • Solutions
    • Claim Analytics
      • Data Mining
      • Prospective Claim Accuracy
      • Network & Pricing Optimization
      • AuditPoint
    • Clinical Validation
      • Clinical Review & Resolution
      • Hospital Bill Audit
      • DRG Validation
      • Outpatient Audit
    • Other Party Liability
      • Healthcare Subrogation
      • Property & Casualty Subrogation
      • Pre-Bill Discovery
      • Coordination of Benefits
      • SubroPoint & Troveris
    • Workers’ Compensation
      • Medical Bill Review
      • Clinical & Coding Logic
      • Pharmacy & DME
      • Predictive Analytics
  • Right Direction
  • Newsroom
  • Contact
    • Got a letter?
    • Respond Online
  • Careers
  • Client Login
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