Medical claims audit: technical and administrative review of every invoice.
We review the claims filed by providers with clinical and accounting judgment, to pay what is due and support every objection. More than 30 years of experience, backed by PA Global Network.
A Forum of Firms network
Pay what is due, with support.
A medical claims audit reviews each invoice before payment: that the service was authorized, appropriate, fully supported and billed at the agreed rate. Objections are raised as glosas, with their code and supporting evidence.
When you need it
- Claim volumesexceed the capacity of the internal team.
- Objections do not hold upin reconciliation with providers.
- Medical costsare growing above budget.
- You need to meetthe review deadlines set by regulation.
What we review in each claim.
Each invoice goes through an administrative review and a technical review.
Invoice requirements
Electronic invoice, RIPS records and mandatory supporting documents.
Authorization and coverage
That the service was authorized and covered by the contract.
Rates
Consistency with the rates agreed in the contract.
Medical appropriateness
Consistency between the diagnosis and the services billed.
Clinical support
Clinical record, discharge summary, results and surgical reports.
Objections and returns
Raised with the code from the single manual and their support.
Administrative and technical review.
A defined workflow that meets regulatory deadlines and leaves a trail for every decision.
- 1FilingWe check invoice requirements and the completeness of supporting documents.Resolution 2275 of 2023
- 2Administrative reviewWe validate authorization, coverage and rates.Decree 441 of 2022
- 3Technical reviewPhysician auditors review appropriateness and clinical support.Resolution 2284 of 2023
- 4Objections and reconciliationWe raise objections and support reconciliation with the provider.Law 1438 of 2011
Claims reviewed and objections that hold up.
- Claims reviewed within regulatory deadlines.
- Objections raised with code and support, ready for reconciliation.
- Objection indicators by provider, concept and value.
- Support at reconciliation meetings.
What you should know.
What is a glosa?
It is a full or partial objection to a healthcare invoice, raised with a code from the single manual and its justification.
Which regulation governs objections?
Resolution 2284 of 2023 adopted the single manual of returns, objections and responses. Deadlines are governed by Law 1438 of 2011 and its implementing rules.
Who performs the technical review?
Physician auditors, supported by administrative and accounting staff for rates and requirements.
Can you handle the full claim volume?
Yes. We can take on the full review or support the internal team during filing peaks.
Do you support reconciliation?
Yes. We take part in reconciliation meetings with providers to support the objections.
Services that work together.
Do your objections hold up in reconciliation?
Tell us your claim volume and a partner will send you a proposal.
Audit of medical bills
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Audit of medical bills : systematic, continuous and comprehensive evaluation of medical bills from the administrative , financial and medical relevance sight, according to current regulations and contractual parameters defined by the parties.
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