Pre-Payment Clinical Review,
Built for Accuracy and Defensibility
Pre-Payment Medical Claim Review Services
We deliver clear, evidence-based insights that help you reduce risk, recover value, and make confident decisions.
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We provide detailed review of outpatient facility claims with a focus on coding accuracy, documentation support, and alignment with payer guidelines.
Our reviews identify:
Unbundled or overlapping services
Incorrect units or time-based billing discrepancies
Documentation gaps impacting reimbursement
Opportunities for cost correction prior to payment
All findings are structured, defensible, and supported by clinical documentation and industry standards.
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We conduct precise evaluations of professional claims, focusing on CPT accuracy, documentation alignment, and appropriate reimbursement.
Our review process identifies:
Upcoding or downcoding concerns
Modifier misuse
Duplicate or overlapping services
Documentation inconsistencies
Each finding is supported by clear rationale, ensuring outcomes are clinically appropriate and defensible.
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Our reviews are grounded in clinical documentation, CPT guidelines, and industry-standard billing practices.
Every determination is:
Evidence-based and fully supported
Aligned with documentation and medical necessity
Structured to withstand audit and provider scrutiny
This approach ensures findings are not only accurate—but actionable and defensible.
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We translate complex claim data into clear, actionable reports designed to support decision-making, negotiations, and compliance efforts.
Our reporting includes:
Structured findings with supporting rationale
Clear identification of discrepancies and risk areas
Summary insights for operational and financial impact
Consistent formatting for easy internal use
The result is reporting that is both easy to interpret and ready for real-world application.
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We provide flexible overflow support for payers, TPAs, and cost containment teams experiencing increased claim volume or resource constraints.
Our overflow model allows organizations to:
Maintain turnaround times during high-volume periods
Reduce backlog without increasing internal burden
Pilot pre-payment review with minimal risk
Extend internal team capacity without workflow disruption
All overflow reviews follow the same structured, RN-led methodology—ensuring consistency, quality, and defensibility.
Ideal for pilot programs, backlog reduction, and targeted high-cost claim review.
Real Review Example
A sample outpatient claim review demonstrating how structured, clinical analysis identifies discrepancies and supports confident decision-making.
Scenario
A high-level emergency department visit (billed as CPT 99285) was submitted with multiple additional services, including IV hydration and medication administration.
What Was Billed
99285 – Emergency Department Visit (Level 5)
96374 – IV Push Medication
96361 – IV Hydration (additional hour)
J1885 – Injection, ketorolac
71046 – Chest X-ray (2 views)
93005 – ECG tracing
Outcome
Recommended adjustment from 99285 → 99284
Removal of unsupported hydration add-on (96361)
All other services supported and retained
Review Focus
The claim was evaluated for:
Appropriate E/M level selection
Documentation support for IV hydration duration
Proper use of medication administration codes
Potential duplicate or overlapping services
Client Value
This review identified discrepancies that may have resulted in overpayment while preserving appropriately billed services. Findings were supported by CPT guidelines and documentation review, enabling confident pre-payment decision-making.
Key Findings
E/M Level Review: Documentation supported a moderate complexity visit. Level 5 billing (99285) was not fully supported.
IV Hydration: Time-based requirements for additional hydration hours were not documented.
Medication Administration: IV push medication (96374) was appropriately billed and supported.
Diagnostics: Imaging and ECG services were supported and appropriately billed.
Application
This example is for illustrative purposes and reflects a
de-identified claim scenario.
See how this level of review can support your organization.
Request a Consultation
Submit a brief request and we will follow up within 1-2 business days to discuss your needs, including pilot and overflow support opportunities.
We’re happy to begin with a limited set of claims to demonstrate our approach and value.
All inquiries are handled with discretion and professionalism. We maintain strict confidentiality and secure handling of all information in accordance with industry standards.