Clinical Audits
STAR’s Clinical Team have extensive experience in a wide range of clinical areas. Our Reviewers use their expertise to address clinical validation, compliance, accuracy, and review of medical record documentation for optimal and accurate quality data and reimbursement. Our services target both Acute Care Inpatient records as well as a full Outpatient clinical documentation review. Click on each of the following types of audits to learn more about how our team can help your organization.
Utilization Review / Management (UR/UM) & Medical Necessity Auditing
A vital component to ensuring quality improvement and compliance with national standards and recommendations for care, and in preventing denial of payment for services or procedures.
UR/UM and Medical Necessity Auditing helps healthcare organizations enhance patient care, control costs, improve compliance, and ensure optimal utilization of healthcare resources. These processes contribute to delivering high-quality, cost-effective healthcare services while promoting patient safety and positive outcomes.
STAR’s Clinical Reviewers conduct focused, retrospective reviews to confirm that the care was appropriate and was provided at the most efficient and effective level. They will determine if the codes used to describe the care on the submitted bill are coded correctly according to CPT & ICD-10 standards. These retrospective reviews also provide an opportunity to collect data related to the quality of care, compliance with national standards, and additional outcomes data that can be shared with providers and throughout the organization.
STAR Clinical Reviewers have extensive experience with UR/UM Auditing on both the payor and provider side. They are well-versed in CMS guidelines, as well as Local Coverage Determinations (LCDs) and National Coverage Determinations (NCDs) where they apply. Because our reviewers are also clinicians, they have deep knowledge of MCG (formerly Milliman Care Guidelines) evidence-based criteria.
Clinical Validation Auditing
Clinical validity is a primary focus of Medicare Advantage and commercial payors, and clinical validation is the most frequent reason for DRG payment reductions.
Clinical Validation Auditing focuses on ensuring the accuracy and completeness of clinical documentation to support the medical necessity of services provided. STAR’s Clinical Reviewer RNs work in conjunction with our Coding/DRG Validation team to validate each diagnosis or procedure documented within the health record, ensuring it is supported by clinical evidence in the medical record. CMS does not permit providers to submit claims with codes for conditions that cannot be clinically validated based on authoritative and/or widely accepted diagnostic standards if it results in an “overpayment.”
STAR’s Clinical experts are experienced on both the payor and provider side. They have conducted Medicare/Medicaid recoupment audits and are well-versed in CMS clinical indicator and clinical documentation diagnostic criteria. Our team will apply their knowledge and experience to help you shore-up your organization’s practices to prevent denials and recoupment issues.
Two-Midnight Rule Audit (Inpatient vs. OBS)
By ensuring that patients are assigned the correct level of care, facilities can decrease their risk of an OIG audit.
The "Two-Midnight Rule" is a Medicare policy that determines whether a patient's hospital stay is appropriate for Medicare Part A reimbursement as an inpatient admission or should be billed as an outpatient observation stay. In 2022, the Office of the Inspector General (OIG) announced that they would resume audits of short stay admissions to determine hospital compliance with the “Two-Midnight Rule”.
STAR Clinical Reviewers have conducted these OIG audits themselves and are knowledgeable about the regulatory requirements that govern hospital billing of services and are intimately familiar with the MCG (formerly Milliman Care Guidelines) evidence-based criteria (an additional tool commonly used to determine appropriate level of care by OIG).
Our expert reviewers will conduct an assessment of your short-stay admissions and make determinations of appropriate level of care based on both clinical expertise and established, evidence-based inpatient admission criteria. Based on the findings of these reviews, we will provide customized education to your clinicians, utilization management and coding and billing staff.
Medicare Administrative Contractor (MAC) Auditing
When Medicare Claims are submitted accurately, everyone benefits.
STAR Medical Record Reviewers are well-versed in Medicare Administrative Contractor (MAC) projects, providing the following services:
Conduct Targeted Probe and Education (TPE) reviews for various CPT codes.
Perform Medical Pre-Payment Claim Reviews for Medicare Part A and Part B claims.
Make reasonable payment determinations based on clinical information and established criteria and clinical guidelines.
Determine whether documentation supports medical necessity and is reasonable and appropriate for coverage and reimbursement.
Educate providers regarding medical reviews, coverage determinations, coding procedures, etc., in accordance with CMS guidelines to decrease billing errors.
Supplemental Medical Review Contractor (SMRC) Auditing
Monitoring claims for compliance with coverage, coding, payment, and billing requirements.
·Our reviewers have extensive knowledge and experience with SMRC “Program Integrity” projects.
STAR Medical Record Reviewers review providers and/or claims that are under suspicion of fraud due to prior analysis of outliers (overpayment, over-utilization, etc.)
Prepare professional documents, citing references and guidelines to support claim determinations.