Medical Necessity Evaluation

Use of evidence-based clinical decision-making criteria, Sepsis 3, the Two Midnight Benchmark, and proprietary MCG and InterQual filters, to defend denied claims and validate the appropriate level of care. Our reviews ensure the intensity of services provided matches the patient’s severity of illness and the designated care setting.

We apply rigorous threshold analysis and evidence-based benchmarking at the point of admission to ensure clinical evidence accurately supports an acute-inpatient level of care. Given that inpatient admissions carry the highest financial and regulatory stakes in the revenue cycle, this precise validation is essential to distinguish legitimate acute admissions from observation status.

Two Midnight Rule Compliance

We review clinical documentation for admission-status decisions that align with Two Midnight Rule compliance and CMS coverage criteria. Standardized review protocols are integrated into admission workflows to establish a defensible clinical narrative, thereby preventing status-related denials before a claim is ever submitted.

Clinical Validation Reviews

We perform forensic documentation reviews to verify that physician diagnoses within high-weight DRGs are objectively backed by clinical evidence. By scrutinizing ICD-10 codes for high-impact conditions like sepsis and respiratory failure, we confirm legitimate CC/MCC qualification to secure accurate reimbursement.

Acuity & Level-of-Care Verification

We verify ICU, intermediate ICU, and NICU service intensity against severity of illness by providing evidence-based support to challenge inappropriate coding and unnecessary high-acuity stays.

ED Facility Level Methodology Review

Our ED facility-level methodology aligns billing with national standards by comparing documented and billed care to ensure accurate level assignment and strengthen revenue integrity. We evaluate ED facility billing to ensure E&M level assignments reflect clinical complexity and meet payor methodology standards.

Post-acute reviews evaluate care delivered after the acute hospital stay, such as long-term acute care, skilled nursing, inpatient rehabilitation, home health, and follow-up therapies, for medical necessity, level-of-care appropriateness, and adherence to payor benefit design and EMTALA post-stabilization standards.