Five percent or more of healthcare provider insurance claims contain data entry mistakes, incorrect coding or other errors. Such errors can add up to millions of dollars in improper payments made by healthcare payers. 

Both government and commercial payers have reduced improper payments for medical and pharmacy claims using CGI’s recovery audit contractor programs or business process services (BPS).

Since 1990, our CGI ProperPay solution, including our recovery audit business process services, has helped clients recover more than $3 billion by predicting, identifying and recovering improper claims. 

We combine the advanced technology of CGI ProperPay—including automation, predictive analytics, artificial intelligence and machine learning—with deep subject matter expertise and knowledgeable personnel to identify errors and ensure accurate claims reimbursement. 

Recovery audit services are provided by our U.S.-based shared service center staffed by credentialed professionals, such as doctors, registered nurses, licensed therapists, pharmacists, health information management professionals, fraud investigators, CPAs and IT experts.

Recovery audit BPS scope

Our audit scope covers all provider types with a focus on payment issues that have a high rate of error and yield a return on investment. Examples include:

  • Inpatient auditing – identifies inpatient claims for medical necessity review, as well as those with potential coding and billing errors. We screen inpatient claims for potential upcoding, diagnosis sequencing errors, place of service issues and Diagnosis Related Grouping (DRG) creep.
  • Outpatient auditing – identifies hospital outpatient coding errors. Outpatient claims are screened for coding errors and inappropriate coding, unbundling and case rate violations, medically unlikely edits, as well as documentation, payment window and contractual issues.
  • Professional auditing – identifies and corrects improper CPT-4 coding to eliminate inappropriate billing and revenue optimization of professional claims. Our process includes Medicare’s Medically Unlikely Edits (MUEs) and National Correct Coding Initiative (NCCI) edits.
  • Allied health – CGI customizes edits for all types of allied health claims data to identify claims that have potential billing discrepancies such as upcoding, unbundling of charges, duplicate payments, policy violations, duplicate charges across various providers, date of death and others.

We also apply our experience in claims auditing and recovery to provide a provider education solution. We deliver provider outreach, data and program analytics, value-based healthcare program management and data consolidation and integration services.