MAS auditors examine medical records and patients' bills to identify charges for denial and ensure that all billing is accurate, complete and properly documented.

MAS reviews all paid claims data based on specific criteria to identify claims of interest that are:

  • Reimbursed at a percentage of billed charges
  • Outlier payments
  • Inpatient stays with observation charges
  • High charges for length of stay or procedure performed
  • Historically overbilled by provider

Once all claims of interest are identified, MAS sends a request for patient UB-04s and charge details to identify hospital-billed charges that contain:

  • Apparent erroneous charges
  • Implant charges that do not match procedure or appear incorrect
  • Duplicate charges
  • OR time that appears excessive based on procedure performed
  • High dollar drugs charged in quantities higher than typically recommended for treatment
  • Charges identified as “non-allowed” by health plan

MAS contacts the hospital to schedule on-site review of medical records by a nurse auditor to verify that:

  • Charges represent services or items that were delivered to the patient
  • All drugs, dosages, frequencies and lengths of therapies, ancillary services and specialty items were ordered by a physician
  • Allowed by the plan
  • Any underbilled or unbilled charges are noted

The nurse auditor meets with hospital assigned representative(s) to conduct an exit review. MAS completes the audit process by ensuring the hospital is aware of its findings and has had ample opportunity to present all documentation available.

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