Provider Payment Audits
Provider fraud and overpayments is a significant problem for government health plans. Our proven audit processes and technology detect provider overbilling and overcharging. It utilizes electronic data mining tools and analysis to determine whether providers are accurately adhering to regulatory and contractual obligations, benefit plan designs, and financial agreements. We audit providers across the continuum of care; inpatient, outpatient, professional, pharmacy, DME, home health and nursing care.

HDMGS’ auditors and data analytics answer the following question:

• Were services billed by providers actually provided?
• Do the services, place of service and diagnosis on the claim reconcile with the medical chart records?
• Are there duplicate billings and/or payments by the provider?
• Do the provider records substantiate that the services were rendered on the dates for which the claims were submitted?
• Are the providers following appropriate rules and regulations?
• Do the providers have appropriate credentials?
• Is the provider enrolled with the plan at the time of service?

Cost Report Audits
Under government programs certain providers receiving payments are subject to cost report audits. HDMS conducts cost report audits of provider’s financial and statistical records in order to determine the propriety of the costs claimed on the submitted cost report. Our cost report auditing ensures that program payments were made on the basis of allowable cost of covered services and ensures the reliability of information reported on the cost report. The foundation for our cost report audit approach is published regulations outlining the requirements and basis for compliance.