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As a health payer / insurer, you need a robust claims integrity process that improves coding accuracy and minimizes healthcare provider abrasion. CGI sets the standard with an industry-leading 96% appeal-uphold rate.

We provide access and transparency of audit findings to you and your hospitals and providers to create a more robust claims integrity process. The relationships we build with you and your provider community not only reduce provider abrasion, but ultimately improve coding accuracy through partnership and education.

 

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Hospital inpatient

 
  • Coding validation
  • Clinical validation
  • Short stay outliers
  • Outlier charge review
  • Medically necessary admission
  • Discharge status validation
  • Related readmission
  • Avoidable readmission
  • Hospital acquired condition review

Hospital outpatient

 
  • Canceled procedures
  • Inappropriate modifier usage
  • Medical necessity
  • Policy compliance
  • Device credit review
  • Line-item charge review
  • Trauma team and emergency room levels
  • Observation hours
  • Diagnostic/therapeutic radiology

Professional providers

 
  • Facility/professional mismatch
  • Ambulance services
  • Anesthesia billing
  • Inappropriate modifier usage
  • Durable medical equipment billing
  • Evaluation and management review
  • Policy compliance
  • Medical necessity
     

Recovery audit process
CGI's recovery audit process starts with secure receipt of claims and continues through analysis, audit and provider coordination.