Medical reviews serve an important function when they are used for to check compliance for billing and coding errors. It is important that the billing is made according to the client services provided and that the medical coding matches the services that were delivered. Reviewers and specialists look for coding and billing error by identifying which cases that are presented do not match the predetermined targets for similar procedures. Not only is the billing for the procedure checked for accuracy and matched against the appropriate coding, the total billed is checked again the average procedural costs and cost allocations allowed per day in order to find any anomalies. This insures that the average targets are maintained. When these services are provided on a continuous basis, any billing or coding that is not within the pre-set parameters that were identified, is flagged for further investigation. During the entire audit procedure the confidentiality of the patient record is ensured.
Services that are provided must be consistently and accurately documented for billing and coding. In addition it is important to set the rate utilization and have a measurement of quality. One of the difficulties is with capitated programs. Capitation means that the facility receives a set payment per patient per month regardless of the medical care received. The organization that participates in such capitation programs are required to provide a minimum of the standards of care for the areas that they agree to cover. If the patient needs to see the doctor for a serious illness that is covered under a capitation program, the provider is obligation to provide the medical services as required to take care of the condition. There is a disincentive for the providers under a capitation program to prepare reports with accurate information because they do not get any financial benefit for doing so. Because of this the data reported under capitation programs is less than reliable. In these cases, a medical review which is an audit of the medical records can provide the validation of the data in the medical records to see that the patient records match the services that were provided.
This validation is a necessary step to ensure that the vital functions are provided under the capitation contract agreement and that the quality of care provided meets the terms of the agreement. Medical reviews of capitation programs include assessment of the quality and completeness of the data collected, and offer advice for the improvement of the system.