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.