Inpatient Hospital Care Validation
Short-Stay Review encompasses the in-depth review of a patient’s medical records to determine the correct level of care that should be considered on a claim by claim basis. Claims that should have been paid under a lower level of care can equate to savings. In addition to saving money on paid claims, our unmatched team of professionals often uncovers non-compliance issues that could lead to better contracts and future savings.
Performed by a Registered Nurse (RN), Short-Stay Review begins by screening for good candidate claims from the data provided. Using recognized admission criteria, CMS guidelines and industry knowledge, HealthMind validates that the inpatient stay was medically necessary, reasonable and appropriate for the diagnosis and condition of the patient. If a claim does not meet appropriate guidelines, the provider is informed and the team proceeds to obtain sign-off.
What We Find:
- Claims in which patients went through the ER but then should have been observed, not admitted
- Claims in which patients received elective surgery during short stays that should have been an outpatient procedure
- Claims in which the admitting physician had ordered observation services but inpatient was inaccurately billed