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Clinical Claim Review Services
Contract Compliance Audit (CCA) Services
To stem escalating healthcare costs, payers often overlook billing and reimbursement errors caused by misapplied or misinterpreted policy or other payment terms for various ancillary services. These errors can be significant and require specific policy review experts that can understand the origin of the problem and recommend a solution.
CCA is an intensive review service that evaluates multiple areas of specialized care and treatment administered in a physician or outpatient setting. These treatments involve complex policy terms that often cause billing errors.
Contract Compliance Audit areas of focus include:
How it Works
Claims associated with complex policy terms present administrative challenges. Analysts screen these claims using a combination of clinical expertise, contractual review and historical experience, identifying areas of potential overpayment. EquiClaim, an Emdeon company, obtains treatment plans and physician orders to validate the billed claim and the provider reimbursement policy. If EquiClaim, an Emdeon company, identifies overpayment, it notifies the provider and allows them to submit additional documentation that supports the original billing. After this process, overpayment recovery begins.
Value Points
- Cost containment for unregulated, high-cost specialty services with high savings potential
- Productive post-payment tool for controlling home infusion/DME costs, which are often under-scrutinized
- All CCA reviews are customized to the client's policy or policies and reimbursement methodology
- CCA results can be used to improve and strengthen future specialty contracts and provider policies
- Additional filter to maximize post-payment savings recovery, on top of traditional Hospital Charge Audit or DRG Review Services