Zelis Expert Claims Review® is a robust solution designed to fortify payment integrity operations by thoroughly reviewing medical claims. It employs a team of experienced clinicians—including nurses, physicians, and pharmacists—alongside certified coders to conduct in-depth reviews of inpatient, outpatient, and professional higher-dollar medical claims. This meticulous process aims to uncover coding errors and inappropriate charges, ensuring claim payment accuracy and improving savings on costly claims. The solution offers a comprehensive pre- and post-payment approach, utilizing itemized bill review, clinical chart review, and diagnoses-related groups (DRG) validation to focus on billing compliance, cost analysis, financial outliers, and adherence to plan policies and billing standards.

Key Features & Benefits

• Itemized Bill Review: Conducts a line-by-line examination of complex claims, leveraging human expertise and advanced technology to identify incorrect coding and billing errors that often contribute to overpayments and decreased savings.
• Clinical Chart Review: Performs clinical reviews of itemized bills and medical records to identify clinical inaccuracies and ensure claims are billed appropriately according to the payer's medical policies, including reviews of high-cost drugs.
• DRG Validation: Validates diagnoses-related groups to ensure accurate coding and billing, contributing to overall payment integrity.
• Pre- and Post-Payment Review: Offers a comprehensive approach by reviewing claims both before and after payment, enhancing overall payment accuracy and reducing administrative waste.
• Advanced Technology Integration: Combines human expertise with advanced technology to optimize the claims review process, ensuring efficiency and accuracy.