Medical Claims Audit and Recovery

A typical medical claim process includes documenting the service, translating documentation into charges and codes, checking eligibility or authorization requirements, submitting and adjudicating the claim, and posting payment or resolving the remaining balance. Infectious disease claims may also require attention to drug, infusion, E/M, OPAT, or consult details. Exact workflows vary by payer, service, and practice systems.

The two broad claim formats are professional claims and institutional claims. Professional claims generally represent services delivered by physicians or other individual providers, while institutional claims represent services billed by facilities. Infectious disease practices should also distinguish the benefit and billing context for drug, infusion, hospital consult, and outpatient services when reviewing payment accuracy.

First confirm the overpayment by comparing the remittance, contract or payment terms, claim details, and account history. Then document the reason, notify the relevant payer or party, and follow the applicable refund, recoupment, or correction process. Keep an audit trail of communications and adjustments. Practices should also check whether the issue reflects a broader payment or configuration pattern.

A medical claims audit can review coding, documentation support, charge capture, claim submission, payer adjudication, payment posting, denials, contract terms, and outstanding balances. For infectious disease practices, the review may include E/M, drug, infusion, OPAT, and hospital consult claims. The objective is to identify unsupported charges, missed revenue, underpayments, recurring denials, and unresolved A/R.

Underpayments are identified by comparing actual reimbursement with the amount expected under the applicable contract, fee schedule, or documented payment terms. The review may examine drug and administration reimbursement, E/M payment, units, NDC information, and payer processing. Confirmed short-pays can then be disputed, tracked, and analyzed for recurring causes that may require contract or workflow changes.

An infectious disease practice can audit office visits, hospital consults, infusion administration, drug claims, OPAT-related services, and other claims supported by its documentation and contracts. Reviews may be organized by payer, provider, service line, claim status, or balance. The most useful scope depends on the practice’s revenue streams, systems, and known payment or denial concerns.

Effective denial management groups denials by root cause rather than treating every rejected claim as an isolated event. Common review areas include coding, documentation, authorization, medical versus pharmacy benefit assignment, and claim submission errors. Appeals should be supported by the relevant clinical and billing records, while trend reporting helps teams correct workflows and reduce repeated denials.

Useful information may include claims, remittance details, payment records, payer contracts, fee schedules, denial and rejection reports, aging A/R, coding or charge data, authorization records, and documentation relevant to the services reviewed. Organizing information by payer, service type, provider, and balance can make patterns easier to identify. Practice-specific figures are essential because generalized rates may not apply.