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Medical Claims Audit & Recovery 2017-01-06T14:49:24+00:00

Medical Claims Audit & Recovery Services
Contract Compliance and Payment Integrity

For two decades, FRG has been raising the bar for medical claims audits – and the healthcare financial recovery industry.

Medical Claims Recovery

FRG audit services uniquely blend high-volume data mining processes with customer- and claim-specific senior auditor sample reviews to deliver top quality payment accuracy assessments.

Since 1999, FRG has provided medical claims audit and recovery services to a number of national and Florida-based health plans. We offer ad hoc and ongoing support engagements and provide claims re-pricing, overpayment analysis, recovery letter, collections and payment-posting services. We have recovered tens of millions of dollars for our clients by auditing claims across the spectrum of contract and health plan types.  Our expertise covers Fee for Service, Capitation, DRG, Per Diem, Carve-Outs, Outpatient Surgery, Billed Charges and a variety of bundled payment arrangements for national Medicare plans and ten state-based Medicaid managed care plans.

For each client, FRG deploys its unique and proprietary data processing system and expert team. For each medical claims audit, or in each recurring audit cycle, we apply state of the art technology through multiple in house Statistical Analysis Software SAS® servers to stratify volume by place of service, by facility, by type of claim and by other natural common dimensions as dictated by the data itself. Once stratified, all or a subset of the claims from each strata (selected by multistage sampling to draw an appropriately sized random set) are programmatically screened for overpayment and flagged for review by our experienced medical claims auditors, each with a minimum of twenty years auditing claims payments for accuracy, timeliness of payment and coordination of benefits. In addition, due to the usual magnitude of spend involved, hospital contracts are sampled proportionally according to either size or a measure of complexity of the contract and subject to additional scrutiny.

Our team’s expertise covers adjudication by multiple claims systems including Xcelys, Facets and proprietary third party administrator systems, and our accuracy is unmatched. Our largest and most tenured client has benefited from the use of our system and processes for five years. Its leadership repeatedly declared that our process produces the lowest error rate of all vendors contracted by the plan to support its medical claims audit and recovery function. Each year, by leveraging automation and applying expertise, our typical discovery rate is approximately 50 basis points of the total claim volume with annual individual auditor productivity around $1.3MM per year.

“We utilize several payment audit firms at our insurance company. Month after month FRG continues to find items that the national audit firms miss. FRG is quick to respond to changes in our business and have provided white papers to me and my staff understand the impact and root cause of why overpayments occur.”
VP Finance, National Health Plan
“I can’t say enough about the staff of FRG. The service they’ve provided our business is the absolute best. Always prompt, always professional and always proactive, the experts at FRG take care of our provider reporting so we can take care of business.”
Director of Financial Recovery

FRG’s Audit & Recovery Results at a Glance

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Medical Claims Audited Yearly
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Average Recovered Overpayments per Client
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Medical Claims Audit & Recovery Experience

Making Sense of Medical Claims Data

Employing proprietary healthcare software programs, FRG has streamlined and improved medical claims audit outcomes to greatly reduce overpayments. Data mining programs run against large claims databases extracting only the claims identified as “outliers” in seconds. These programs enable an unparalleled level of data mining defined by quantitative/qualitative healthcare and financial analytics criteria.

  • Analysis of health plan-specific weaknesses
  • Broad industry trends and issues
  • Provider history and experience
  • Trends in services flagged by historically high levels of overpayment
Medical Claims Audit Process

Who We Help

MSOs, IPAs and Physician Groups

Easily Identify Performance Improvement Opportunities

Healthcare Management Services Organizations

Use AccuReports® to understand trends and measure care management effectiveness

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Health Plans (Government and Commercial)

Align Incentives through Performance Transparency

Tools for Health Plans & HMOs

Use AccuReports® to efficiently communicate performance on financial and quality metrics over the web.

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Accountable Care Organizations (ACOs)

Understand Medical Cost Dynamics and Take Action

Accountable Care Organizations Solutions

AccuReports® presents your CCLF data as interactive profit and loss statements.

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Healthcare Consultants

Let FRG Provide your Medical Economics Infrastructure

Take Your Clients to the Next Level

FRG has decades of experience organizing medical economics data into meaningful reports. Leverage our tools to speed your assessments.

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