For over 14 years, SCIO® has partnered with Payers, Health Plans and PBMs to optimize reimbursement. Through a blend of audit services, workflow technology, payment analytics and clinical reviews we help clients detect, prevent and recover improper payments across the payment lifecycle. Clients benefit from our platform versatility, sophisticated analytics, operational expertise and clinical knowledge.

Medical Claims Auditing

Our medical claim auditing services ensure our clients are controlling costs most often associated with incorrect billing and overpaid medical claims, improving both administrative and medical loss ratios. Our experience and extensive knowledge of auditing different types of medical claims has placed us at the leading edge of audit firms addressing billing errors and payment integrity. We employ rigorous validation, extensive quality checks, robust industry research and ongoing education to ensure we continuously deliver impressive results to our clients. We perform both on-site and desk audits for various types of medical claims including:

  • Inpatient claims ( DRG, % Charge, Short Stay)
  • Outpatient claims (APC)
  • Ancillary Facility claims ( SNF, Home Health, DME, High Cost Drug)
  • Professional claims ( E&M Coding)
  • Other Party Liability ( Subrogation)
  • Fraud Waste and Abuse (SIU Models)

Learn how to maximize Payment Integrity effectiveness.

Learn how to maximize Payment Integrity effectiveness.

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Pharmacy Claims Auditing

With a pharmacy-friendly process, SCIO® helps its clients minimize pharmacy abrasion during the audit process.  A systematic method is used to review all pharmacy claims, with analytics performed based on prescribing patterns, utilization overrides, ingredient cost integrity, geographic prescribing reports, payment reports, and billing issues to identify potential overcharges.

Our staff has vast expertise in a variety of pharmacy settings, including mail order, home infusion, long term care and chain, regional and independent retail pharmacies. Our audit staff includes expert pharmacists, state pharmacy inspectors, healthcare attorneys, and individuals that have worked with PBMs as well as mail order, long term care and specialty pharmacies.

SCIO’s pharmacy on-site and desk claims audits focus on:

  • Pharmacy Compliance
  • Overpayment Identification
  • Fraud, Waste and Abuse

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