Medical Review

Medical Claims Review Services

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In the health care industry alone, billions of dollars are lost every year from fraud, waste and abuse. Overbilling, phantom providers, durable medical equipment (DME) scams, and improper payments are just a few reasons why our medical review team are an integral part of reducing these financial losses. As a result, we obtain financial recoveries from a wide array of healthcare providers and other organizations.

If you would like to discuss our medical claims review services and how they can benefit your organization, contact one of our specialists today. You can reach us by phone at  (703) 683-9600 or click here to fill out our online contact form.

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Our Medical Review Services

Our medical review team is capable of conducting health care program evaluations across a wide-variety of service areas and clinical topics including, but not limited to:

  • Medicare claims audits and reviews
  • Medicaid claims audits and reviews
  • Fee-for-service claims reviews
  • Managed care reviews of health care services and pharmacy

The team includes a pool of subject matter experts covering a wide variety of medical specialties, care management, behavioral health, and pharmacy. These experienced medical directors, medical review nurses, certified coders, and fraud analysts are able to conduct claims reviews and determine medical necessity or potential fraud, leveraging an average of 25 years of medical experience.

Medical Review Contract Examples

The Medical review team has supported various federal government program integrity efforts in key personnel rolls on contracts at the Centers for Medicare & Medicaid Services (CMS). Examples of specific contract work we have been involved in include:

  • CMS Zone Program Integrity Contract – Zone 1
  • CMS Program Safeguard Contract – New England Benefit Integrity Support Center(BISC), Eastern Area BISC, and Pennsylvania BISC
  • IntegrityM is also supporting a state DRG Auditing Services contract providing Medical Billing Code Review

Click here to learn how our medical review team supports UPIC efforts.

How We Are Different

IntegrityM’s multi-disciplinary staff is widely scalable, allowing for immediate medical review staffing needs.  We maintain a pool of experts that have knowledge in a variety of schemes and fraudulent activities and can work around the country.

Contact Our Medical Review Specialists

If you would like to speak with one our experts about medical claims review services, click here to contact us today, or call  (703) 683-9600

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