Medical Claims Review

CFMC's medical claims reviewers compare billing records with medical records to determine the payment accuracy. This service is provided to payers who want to ensure they are only charged for services delivered, and to providers who want to ensure they are billing for all services delivered.

Typically, medical claims reviewers focus on patient bills that fall outside determined cost and day parameters (outliers). Physician orders are carefully checked to make sure services delivered were ordered by a physician. Our payer clients and provider clients are given the opportunity to comment on reviewer findings before conclusions are compiled in a final report. Throughout the review process, we guarantee confidentiality of all patient records.

CFMC can perform medical claims review as an ongoing service or on a temporary basis. For instance, a review may be appropriate when a specific need arises or when in-house staff members need assistance with high volumes. Our medical claims review customers have included the Centers for Medicare & Medicaid Services, the Office of the Inspector General, health plans, attorneys, and hospitals.

Contact Nancy Borgstadt, RN, MS, CNS, director of review services at 800.950.8250 ext. 3153, or e-mail Nancy at nborgstadt@cfmc.org.