Medical Review Services & Improper Payment Support

Medical Review Services to Strengthen Compliance and Reduce Improper Payments

IntegrityM delivers independent, clinically driven medical review services that help public and private payers detect improper payments, verify documentation, and strengthen program compliance. Our reviews are grounded in clinical expertise, regulatory knowledge, and audit readiness best practices.

End-to-End Medical Review Capabilities

IntegrityM delivers comprehensive medical review services that help identify improper payments, ensure documentation accuracy, and support compliance with CMS, Medicaid, Medicare, and commercial payer requirements. Our specialists assess claims for medical necessity, coding accuracy, and alignment with applicable policies and guidelines.

Key Areas of Medical Expertise

Our medical review experts assess a wide range of factors, from clinical documentation to coding accuracy and provider behavior.

Pre- and post-payment claims review
Medical necessity and clinical documentation audits
Detection of billing outliers and anomalies
Provider education and engagement strategies
Medicaid and Medicare compliance alignment
Reviews for fee-for-service and managed care programs

Advancing Healthcare Claims Technology

IntegrityM partners with AI and machine learning developers to embed clinical, regulatory, and compliance expertise into the design and deployment of healthcare automation tools. As a trusted healthcare partner, we guide the use of AI/ML technologies in medical coding, claims analysis, and utilization review, transforming complex healthcare data into outcomes that are accurate, compliant, and defensible. Our team ensures your AI outputs are clinically grounded and policy-aligned, helping you build trust with payers and providers in complex, regulated environments.

AI Model Training Support: Deliver datasets and expertise to guide model development, reduce bias, and align with real-world use cases.
Testing & Validation: Conduct scenario-based testing to evaluate model accuracy.
Regulatory Compliance Reviews: Assess AI-generated outputs against Medicare, Medicaid, and payer-specific policies to mitigate risk exposure.
Ongoing Quality Oversight: Monitor AI/ML models post-deployment to detect drift and uphold reliability.

Reducing Improper Payments

IntegrityM works with agencies and payers to reduce improper payments by combining clinical expertise with data-driven audit methodologies.

CPT/HCPCS coding analysis to uncover claim-level inaccuracies
Identification of billing discrepancies and overutilization trends
Detection of patterns associated with potential patient harm
Pre-payment and post-payment audits with clear, defensible reporting
Support financial recovery efforts through defensible findings

Medical Necessity & Documentation Review

Our team evaluates whether billed services are medically necessary, accurately coded, and properly documented according to payer guidelines.

Verifying that documentation clearly supports billed services
Ensuring services are reasonable, necessary, and covered
Alignment with National and Local Coverage Determinations (NCD/LCD)
Safeguarding against falsification or alteration of medical records

How We Support Oversight for Government and Health Plans

IntegrityM partners with oversight entities to bring clarity, structure, and defensibility to medical review activities for federal, state, and private programs.