Claim Savvy Auditing


Conducted prior to claim submission, if documentation does not support the services/codes – documentation should be corrected before submission to health insurance carriers


Conducted after claim submission – includes claim review and payment trends to ensure correct coding and billing practices. Determines if and where mistakes may have been made as well as who made the error



Concentrates on one type of service/code to determine compliance


Concentrates on a random selection of medical records and different types of services/codes to determine compliance


Scope & Statistical Sampling

Non-Statistical Sampling – Based on unique services that were defined in the objective & scope

Proportional Sampling – Built around high frequency items or items considered significant

Numerical Sampling – Based on all possible services within a chosen time frame (random selection)

Data Mining & Data Analytics

Analysis of large data sets to discover patterns and use those patterns to forecast or predict the likelihood of future events


Quality Improvement

Continuously improving processes to meet standards, focuses on processes and systems, and assists with practice “prevention.”  Assists with making each process or workflow in the physician practice or facility function better with the overall process becoming more efficient

  Efficiency: Doing things right

  Effectiveness: Doing the right thing

Quality Assurance

Measures compliance with standards, focuses on individuals, and assists with practice “inspection.” System of management involving planning, training, quality control, assessment, data review, reporting, and quality improvement to ensure a process or service is of the expected quality