CASE STUDY · CS-01
Trauma DRG miscoding
A clean claim every scrubber would have paid.
$230KTotal savings
POST-SERVICE
Forensic Claims ValidationPhysician review of the full medical record
Find the improper payments automated edits miss.
- Health plans & TPAs
- Stop-loss & reinsurance
- Legal & compliance
Discuss claims validation46% AVG. SAVINGS
CLAIMS UNDER REVIEWLIVE
- CL-26-11402 · DRG 003Determined
- CL-26-11417 · INPATIENTIn review
- CL-26-11423 · SURGERYIn review
- CL-26-11431 · IMAGINGReceived
The problem
A 50% discount on an inappropriate claim is still an inappropriate payment.
Most vendors review the claim. Avandé reviews the care behind it.
Overview
What we do.
Forensic Claims Validation is Avandé’s physician-led review of high-cost claims. Physicians and certified coders read the complete medical record to confirm billed care was necessary, documented and supported.
Key benefits
- Pay only for supported careFULL MEDICAL RECORD REVIEW
- Savings beyond your discounts46% AVG. SAVINGS
- Fewer improper paymentsPHYSICIAN + CERTIFIED CODER FINDINGS
WHAT WE CATCH
- Unsupported admissions
- DRG miscoding
- Excessive services
- Misrepresented clinical findings
- Inappropriate treatment pathways
- Fraudulent billing
HOW IT WORKS
Four steps. One standard.
- Received
Step 01: Claim flagged
- In review
Step 02: Records requested
- In review
Step 03: Physician and coder review
- Determined
Step 04: Findings and recovery
EVERY STEP RUNS ON ANSERA PORTAL
Results
Measured, not promised.
46%Avg. savings over existing discounts
$51MTPA A · 10-year savings
$14.1MStop Loss A · 10-year savings
Why Avandé
We review the medicine.
Our largest savings came from claims every other reviewer had already approved.
- SOC 2 Type II
- HIPAA
- BAA
- PHI Protection
| TYPICAL VENDOR | AVANDÉ |
|---|---|
| Checks codes and payment rules | Reads the full medical record |
| Discounts the bill | Eliminates inappropriate payments |
| Accepts claims at face value | Verifies every clinical assertion |
FAQ
Straight answers.
Unsupported admissions, DRG miscoding, excessive services and misrepresented findings, found in the full medical record.
Board-certified physicians working with certified coders.
High-cost and flagged claims, prepayment or post-payment.
46% average savings, over and above your existing discounts.
Talk to a physician-led team
Discuss claims validation.
A few sentences are enough.