The Focused Claims Review program has proven itself to be a money-saving feature for UnitedHealthcare's fully insured customers, and it is now being extended to our self-funded customers.
The program is a unique post-service pre-payment claims verification program that helps generate cost savings by auditing claims to find billing errors that cannot be identified by computer-based claim editing programs and other automated claims processing. The program goes beyond standard bill and claim audit capabilities leveraging board-certified physicians that compare selected physician claims with surgical notes; identifying and preventing payment of submitted claims that do not describe the services actually rendered.
The Focused Claims Review program applies to claims that are orthopedic and other procedural-based services (e.g. cardiology, neurosurgery, podiatry, otorhinolaryngology or ears, nose, throat (ENT), urology and dermatology).
- Most overpayments occur when claims are submitted with codes that do not match the description of services rendered; automated tools do not compare procedure codes to surgical/procedural notes.
- This program enhances the work of existing Payment Integrity Programs by utilizing board-certified physicians to review like-specialty claims.
- The Focused Claims Review program is able to identify errors prior to release of a payment or explanation of benefit (EOB).
For additional information, please reference the Focused Claims Review program brochure or contact your UnitedHealthcare representative.