The high costs associated with an inpatient admission require facilities to document and support the clinical decision to admit a patient.
However, not all hospitals consistently provide accurate and detailed documentation for patient encounters prior to admission. It is therefore imperative that hospitals comply with accepted clinical protocols and industry standards, as dictated by InterQual and MMR clinical criteria requirements, to support an inpatient admission. Even with protocols in place, inappropriate admissions to the inpatient setting cost Medicare and commercial payers hundreds of millions of dollars annually.
The Solution
Inappropriate Admission Review (IAR) of inpatient clinical criteria provides an effective screening mechanism to identify specific claims with a high potential for overpayment based on the level of care, severity of illness and intensity of service provided. Viant's Certified InterQual instructors, Certified Case Managers and Utilization Review professionals review medical record documentation on select claims and document unsupported admissions for recovery of overpayments. This team of clinical review professionals is further supported by our Chief Medical Officer along with a panel of physicians representing more than 36 clinical specialties.
Advantages
- Recovery of overpaid dollars ranges from 30% to 100% of the original paid claim
- Ensures that appropriate qualifying clinical criteria is met before a patient is admitted at the inpatient level of care
- Additional filter to maximize postpayment savings recovery as a supplement to traditional Hospital Bill Audit, Contract Compliance Audit or DRG Validation Services
How it Works
IAR cases undergo a unique data mining routine to identify and target cases with high potential for payment error by applying proprietary algorithms based on our years of experience in utilization review and case management. Viant's IAR data mining logic looks for potential inappropriate admissions, as well as potentially non-covered services that may be medically unnecessary. Viant's IAR process utilizes a library of electronic InterQual databases for all previous years to ensure the highest accuracy and clinical verification. Viant employs a team of highly skilled Registered Nurse professionals who are experienced in utilization review and case management and average more than 20 years of experience, with a minimum of at least five years of InterQual experience. The reviewers must also routinely access the Medicare Coverage database to research National or Local Coverage Determinations and policies.
Summary
Oftentimes hospitals admit patients on an inpatient basis as opposed to providing an alternative and more appropriate level of care in observation or the outpatient department, costing Medicare and commercial payers hundreds of millions of dollars. Viant's IAR service identifies and then reviews specific claims that have a high potential for overpayment based on the level of care, severity of illness and intensity of service provided. On its own or combined with Viant's other post-payment offerings, IAR presents payers with an opportunity to identify savings for inappropriate admissions on inpatient claims. |
