Total U.S. healthcare spending is estimated at $2.4 trillion for 2008, and recent studies have shown that a good portion of that spend is wasted due to improper payments.

The good news is that payers can address the waste from improper payments.

In the past, payers have used limits and exclusions to manage improper payments.  Our experience as a recovery audit contractor for Center for Medicare and Medicaid Services shows that in addition to these two tactics, payers should use post-payment audits to identify and recover overpayments.  These errors, which can be either human or system-related, are a huge untapped opportunity for health care savings.

PRGX identifies potential improper payments made by payers such as Medicare, Medicaid, or commercial by analyzing paid claims data and reviewing corresponding medical records to determine:

• Administrative Compliance: Non-covered benefits, Duplicate payments, Coordination of benefits, Third-party liability, Eligibility determination, Contract compliance, Complex payment terms


• Coding and Billing: Incorrect payments (MS-DRG, APC),  Invalid code assignments (ICD-9®,CPT®), Unbundled services (CPT®),  Inappropriate Modifier Assignment, (CPT®, HCPCS®),  Incorrect Units (CPT®, APC),  Undocumented services (CPT®, APC), Medically unbelievable services (DRG,CPT®, ICD-9® , HCPCS®)


• Medical Necessity: Appropriateness of admissions,  Appropriateness of service

Our physicians, registered nurses, certified coders, and contract compliance specialists use an extensive library of proprietary concepts and algorithms designed to identify inappropriate medical claim payments to improve our clients’ bottom line.